Calgranulin C (S100A12) Is Differentially Expressed in Subtypes of Chronic Rhinosinusitis.

Background Calgranulin C (S100A12) is an innate immune peptide at the air-mucosal interface associated with neutrophil involvement, which when overexpressed has been implicated as a biomarker of inflammatory diseases. Decreased epithelial expression of certain innate immune peptides has been reported in chronic rhinosinusitis (CRS). We hypothesized that S100A12 is differentially expressed in the sinonasal mucosa of patients with CRS compared to controls and that S100A12 is a potential biomarker of CRS-specific quality of life (QOL) and disease severity. Methods A prospective observational study was conducted which included 70 patients: 17 controls, 28 having CRS without (CRSsNP), and 25 with (CRSwNP) nasal polyps. The expression of S100A12 and human neutrophil elastase (HNE) was assessed in the anterior ethmoid tissues from all patients using enzyme-linked immunosorbent assay (ELISA) and immunohistochemical (IHC) analyses. Disease-specific QOL (Rhinosinusitis Disability Index) and disease severity (computed tomography [CT] and endoscopy) were evaluated and correlated to the expression levels of S100A12. Results S100A12 and HNE were significantly elevated in patients with CRSsNP compared to normal controls ( P < .05 and P < .001, respectively) and patients with CRSwNP ( P < .05 and P < .001, respectively), as measured by ELISA and IHC analyses. Patients with CRS exhibited worse CRS-specific disease severity compared to normal controls ( P < .05), and the increased protein levels of S100A12 were significantly correlated to disease severity, represented by CT scores ( P < .05). Conclusions S100A12 is differentially expressed in CRS subtypes and is significantly elevated in patients with CRSsNP and associated with CRS-specific disease severity.

LL-37 causes cell death of human nasal epithelial cells, which is inhibited with a synthetic glycosaminoglycan.

LL-37 is an immune peptide that regulates innate and adaptive immune responses in the upper airways. Elevated levels of LL-37 have been linked to cell death and inflammatory diseases, such as chronic rhinosinusitis (CRS). Glycosaminoglycans (GAGs) are polysaccharides that are found on respiratory epithelial cells and serve important roles in mucosal surface repair. Recent findings suggest that a synthetic glycosaminoglycan (GM-0111) can protect against LL-37-induced sinonasal mucosal inflammation and cell death in a murine model of acute RS. Herein, we elucidated the mechanisms by which LL-37 causes sinonasal inflammation and how GM-0111 can prevent these mechanisms. When challenged with LL-37, human nasal epithelial cells (HNEpCs) and mouse macrophages (J774.2) demonstrated increased release of adenosine triphosphate (ATP) and interleukin (IL)-6 and -8, as well as cell death and lysis. These cellular responses were all blocked dose-dependently by pre-treatment with GM-0111. We identified that LL-37-induced cell death is associated with caspase-1 and -8 activation, but not activation of caspase-3/7. These responses were again blocked by GM-0111. Our data suggest that LL-37 causes cellular death of HNEpCs and macrophages through the pro-inflammatory necrotic and/or pyroptotic pathways rather than apoptosis, and that a GM-0111 is capable of inhibiting these pro-inflammatory cellular events.

[Complications after ileal conduit: Urinary diversion-associated complications after radical cystectomy]. / Komplikationen nach Ileumconduitanlage : Harnableitungsspezifische Komplikationen nach radikaler Zystektomie.

BACKGROUND: We analyzed complications associated with urinary diversion after radical cystectomy (RC) and ileal conduit (IC) for bladder cancer (BCa). PATIENTS AND METHODS: A total of 305 BCa patients after RC with IC were included in the study (June 2003-December 2010). IC complications (peristomal hernia, IC stenosis, stenosis of the ureteral anastomosis, IC bleeding, urolithiasis, urinary infections, and renal insufficiency) were identified according to the Clavien-Dindo classification (CDC). Kaplan-Meier plots were generated. Uni- and multivariable Cox regression analyses with backward selection for prediction of high-grade complications (CDC ≥ III) and IC revision surgery were conducted; covariates included age, previous abdominal/pelvic radiation, body mass index (BMI), previous abdominal/pelvic surgery, comorbidities, and advanced tumor stage. RESULTS: An IC complication (CDC ≥ I) or a high-grade IC complication (CDC ≥ III) was experienced by 32.7 and 13.4 % of our cohort: 14.8 %, 4.3 %, 4.6 % developed a peristomal hernia, IC stenosis, stenosis of the ureteral anastomosis, respectively. IC revision was required by 10.5 % of patients (median follow-up 19.5 months, IQR 7-47 months). The estimated rate of IC complications at 5 years was 52 % (CDC ≥ I) and 22 % (CDC ≥ III). The final model of the multivariable analysis showed that patients with a history of previous radiation (HR 4.33), a BMI ≥ 30 (HR 2.24), or longer duration of surgery (HR 1.01; all p < 0.05) were at higher risk for IC revision surgery. A BMI ≥ 30 (HR 2.49, p = 0.011) was a risk factor for high-grade complications. CONCLUSION: The risk of experiencing a high-grade IC complication is moderate. Previous radiation, obesity, and comorbidities represent risk factors for IC revision surgery. Moreover, obesity is a risk factor for high-grade complications.

Does neoadjuvant therapy for esophageal cancer increase postoperative morbidity or mortality?

Neoadjuvant therapy has proven to be effective in the reduction of locoregional recurrence and mortality for esophageal cancer. However, induction treatment has been reported to be associated with increased risk of postoperative complications. We therefore compared outcomes after esophagectomy for esophageal cancer for patients who underwent neoadjuvant therapy and patients treated with surgery alone. Using the American College of Surgeons National Surgical Quality Improvement Program database (2005-2011), we identified 1939 patients who underwent esophagectomy for esophageal cancer. Seven hundred and eight (36.5%) received neoadjuvant therapy, while 1231 (63.5%) received no neoadjuvant therapy within 90 days prior to surgery. Primary outcome was 30-day mortality, and secondary outcomes included overall and serious morbidity, length of stay, and operative time. Patients who underwent neoadjuvant treatment were younger (62.3 vs. 64.7, P < 0.001), were more likely to have experienced recent weight loss (29.4% vs. 15.9%, P < 0.001), and had worse preoperative hematological cell counts (white blood cells <4.5 or >11 × 10(9) /L: 29.3% vs. 15.0%, P < 0.001; hematocrit <36%: 49.7% vs. 30.0%, P < 0.001). On unadjusted analysis, 30-day mortality, overall, and serious morbidity were comparable between the two groups, with the exception of the individual complications of venous thromboembolic events and bleeding transfusion, which were significantly lower in the surgery-only patients (5.71% vs. 8.27%, P = 0.027; 6.89% vs. 10.57%, P = 0.004; respectively). Multivariable and matched analysis confirmed that 30-day mortality, overall, and serious morbidity, as well as prolonged length of stay, were comparable between the two groups of patients. An increasing trend of preoperative neoadjuvant therapy for esophageal cancer was observed through the study years (from 29.0% in 2005-2006 to 44.0% in 2011, P < 0.001). According to our analysis, preoperative neoadjuvant therapy for esophageal cancer does not increase 30-day mortality or the overall risk of postoperative complications after esophagectomy.

[Clinical and histopathological parameters of prostate cancer: influence of anthropometric indices]. / Klinische und histopathologische Parameter des Prostatakarzinoms : Einfluss anthropometrischer Indizes.

BACKGROUND: Adipose tissue is increasingly considered as an endocrinal active organ and may have an influence on the development and progression of prostate cancer. Adverse body fat distribution, considered a risk factor for cardiovascular disease, is not reflected by the body mass index (BMI). OBJECTIVE: The purpose of this work was to assess anthropometric indices which provide a better estimate of body fat distribution and to evaluate their association with clinical and histopathological parameters of prostate cancer. PATIENTS AND METHODS: In patients scheduled for radical prostatectomy between March 2011 and March 2013, height, weight, waist circumference (WC) and hip circumference were measured, then the BMI, waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) were calculated. The relationships between anthropometric measures and indices and clinical and histopathological features of PCA were evaluated with uni- and multivariate analyses. RESULTS: In 668 patients available for evaluation, obesity rates were 22.8 %, 50.6% and 30.2 % as defined by BMI ≥ 30, WHR ≥ 1 and WHtR ≥ 0.6, respectively. On univariate analysis, WC and WHtR ≥ 0.6 correlated with tumor volume (TV) > 2.1 cm(2) (p < 0.05), respectively. WC and WHtR were independent predictors of a TV ≥ 2.1 cm(2) (p < 0.05) and a WHtR ≥ 0.6 was an independent predictor of a TV ≥ 2.1 cm(2) (p < 0.018, risk ratio 1.506, 95 % confidence interval 1.072-2.115). CONCLUSION: In general a higher degree of adiposity seems to correlate with a higher tumor volume. Whether anthropometric indices have prognostic impact needs to be clarified during follow-up.

Fusion of Magnetic Resonance Imaging and Real-Time Elastography to Visualize Prostate Cancer: A Prospective Analysis using Whole Mount Sections after Radical Prostatectomy.

PURPOSE: To determine whether the fusion of multiparametric magnetic resonance imaging (MRI) with transrectal real-time elastography (RTE) improves the visualization of PCa lesions compared to MRI alone. MATERIALS AND METHODS: In a prospective setting, 45 patients with biopsy-proven PCa received prostate MRI prior to radical prostatectomy (RP). T2 and diffusion-weighted imaging (T2WI/DW-MRI) and, if applicable, dynamic contrast-enhanced sequences (T2WI/DW/DCE-MRI) were used to perform MRI/RTE fusion. The probability of PCa on MRI was graded according to the PI-RADS score for 12 different prostate sectors per patient. MRI images were fused with RTE to stratify suspicious from non-suspicious sectors. Imaging results were compared to whole mount sections using nonparametrical receiver operating characteristic curves and the area under these curves (AUC). RESULTS: 41 of 45 patients were eligible for final analyses. Histopathology confirmed PCa in 261 (53%) of 492 prostate sectors. MRI alone provided an AUC of 0.62 (T2WI/DW-MRI) and 0.65 (T2WI/DW/DCE-MRI) to predict PCa and was meaningfully enhanced to 0.75 (T2WI/DW-MRI) and 0.74 (T2WI/DW/DCE-MRI) using MRI/RTE fusion. Sole MRI showed a sensitivity and specificity of 57.9% and 61% with the best results for ventral prostate sectors whereas RTE was superior in dorsal and apical sectors. MRI/RTE fusion improved sensitivity and specificity to 65.9% and 75.3%, respectively. Additional use of DCE sequences showed a sensitivity and specificity of 65% and 55.7% for MRI and 72.1% and 66% for MRI/RTE fusion. CONCLUSION: MRI/RTE fusion provides improved PCa visualization by combining the strength of both imaging techniques in regard to prostate zonal anatomy and thereby might improve future biopsy-guided PCa detection.

Age and sex differences in the incidence of esophageal adenocarcinoma: results from the Surveillance, Epidemiology, and End Results (SEER) Registry (1973-2008).

Risk factors driving sex disparity in esophageal cancer are unclear. Recent molecular evidence suggests hormonal factors. We conducted a national descriptive epidemiological study to assess the hypothesis that estrogen exposure could explain the male predominance in observed esophageal adenocarcinoma incidence. We analyzed the esophageal cancer incidence trends by histology and sex from 1973 to 2008 in nine population-based cancer registries of the Surveillance, Epidemiology, and End Results (SEER) 9 Registry Database. We used age as a proxy for estrogen exposure in females. The collective age groups annual percentage change in esophageal adenocarcinoma for females is positive (0.03%; 95% confidence interval: 0.02, 0.03%) during the study period. Interestingly, the esophageal adenocarcinoma annual percentage change in incidence rates for females during the same time period is significantly negative from ages 50-54 to ages 60-64. Even though the incidence of esophageal adenocarcinoma rises in both males and females, the male-to-female ratio across age peaks in the 50-54 years then decreases. Furthermore, the esophageal adenocarcinoma age-adjusted incidence rate in postmenopausal females age 80 and above increases with age unlike their male counterparts. Taken together, these data support the hypothesis that the endocrine milieu in pre- and perimenopausal females serves as a protective factor against esophageal adenocarcinoma, and with loss of estrogen or because of the increasing time period away from estrogen exposure, the rate of esophageal adenocarcinoma incidence increases in the older postmenopausal female. Because females comprise the largest portion of the elderly population with esophageal adenocarcinoma, these findings are significant.

[Value of real-time elastography to guide the systematic prostate biopsy in men with normal digital rectal exam]. / Stellenwert der Real-Time Elastografie zur Steuerung der systematischen Prostatabiopsie bei Männern mit unauffälligem digital-rektalen Tastbefund.

The aim of this study was to evaluate whether real-time elastography-guided biopsy in comparison to grey-scale ultrasound improves prostate cancer detection in patients with an unremarkable digital rectal exam.A total of 231 patients suspicious for prostate cancer were prospectively randomised to transrectal real-time elastography- (126) or grey-scale ultrasound (105)-guided biopsy. The peripheral zone was divided into 6 sectors from base, mid-gland to apex. Lesions with reduced elasticity during real-time elastography and hypoechoic areas during grey-scale ultrasound were defined as suspicious for prostate cancer. Prostate biopsy was guided by real-time elastography (RTE) or grey-scale ultrasound (GSU) using a systematic 10-core approach. Suspicious lesions on RTE or GSU in the corresponding randomised group were targeted within each sector. Accuracy of cancer prediction and histopathological cancer detection rates were evaluated and compared between the 2 imaging modalitiesBaseline characteristics of patients undergoing real-time elastography and grey-scale ultrasound, including age, prostate-specific antigen and prostate volume were not significantly different statistically (p>0.05). Overall, prostate cancer was detected in 76 of 231 cases (32.9%). The cancer detection rate was significantly higher (p=0.007) in patients who underwent a biopsy using real-time elastography (40.5%) compared to the grey-scale-guided group of men (23.8%). Sensitivity and specificity to detect prostate cancer in 1 386 prostate sectors was 53.5% and 70.5% for real-time elastography vs. 11.7% and 93.7% for grey-scale ultrasound, respectively.Compared to conventional grey-scale ultrasound, accuracy to detect prostate cancer using a systematic 10-core biopsy approach was significantly improved under the guidance of real-time elastography.

[Cystectomy in elderly patients: analysis of complications using the Clavien-Dindo classification]. / Die Zystektomie im Alter : Komplikationsanalyse unter Anwendung der Clavien-Dindo-Klassifikation.

Radical cystectomy (RC) represents the gold standard in the treatment of muscle invasive urothelial cancer of the bladder. Due to improvements in operation techniques and perioperative care it has become a good and safe procedure even in elderly patients. In recent years the Clavien-Dindo classification has been frequently used for complication assessment in urological research. The Charlson comorbidity index without age correction can be used in treatment planning for RC to identify patients at risk.

A new generation of serotype chimeric infectivity-enhanced conditionally replicative adenovirals: the safety profile of ad5/3-Δ24 in advance of a phase I clinical trial in ovarian cancer patients.

Conditionally replicative adenoviral (CRAd) virotherapy represents a promising therapeutic approach for cancer. We have demonstrated that a serotype chimeric adenoviral 5/3 fiber-knob modification achieves enhanced ovarian cancer infectivity, conditional replication, and oncolytic activity. This study evaluated the safety of intraperitoneal (IP) Ad5/3-Δ24 in advance of a phase I clinical trial in gynecologic cancers. Syrian hamster cohorts were treated with IP Ad5/3-Δ24 or control buffer for 3 consecutive days and euthanized on study days 8, 17, 57, and 89. Blood and tissue samples were harvested from each animal. For biodistribution studies, presence and quantitation of viral levels within samples were determined via quantitative polymerase chain reaction. For safety studies, animals were assessed for adverse vector-related tissue or laboratory effects. In the biodistribution study, low levels of Ad5/3-Δ24 DNA were noted outside of the abdominal cavity. Viral DNA levels in tissues obtained from the peritoneal cavity peaked at day 8 and declined thereafter. In the safety study, no specific histopathologic changes were attributable to virus administration. Hematologic findings noted in the 1 × 10(11) viral particles (vp)/dose group on Days 4 and/or 8 were indicative of an Ad5/3-Δ24-specific generalized inflammatory response; these findings resolved by day 56. The no observable adverse effect level was determined to be 1 × 10(10) vp/dose. This study elucidates the safety profile of IP administration of the serotype chimeric infectivity-enhanced CRAd, Ad5/3-Δ24, and provides guidance for a planned phase I trial for patients with recurrent gynecologic cancers.

[Rising PSA level and negative prostate biopsy. Can prostate elastography help?]. / Steigender PSA-Wert und negative Prostatabiopsie. Kann die Prostataelastographie helfen?

Previous studies investigated the clinical impact of elastography for preoperative staging and as an additional imaging modality to improve prostate cancer detection during prostate biopsy. This rapidly improving technique has facilitated progress toward feasibility and reproducibility of transrectal elastography. Recent studies show significant improvements using the latest generation of elastographic devices. Further studies are needed to evaluate on the one hand elastography-guided prostate biopsy schemes and results of saturation biopsies and on the other hand to compare sensitivity and specificity of elastographic detection of prostate cancer with different imaging techniques, especially magnetic resonance imaging and spectroscopy.

[Ductal Adenocarcinoma of the prostate with infiltration of the bladder. Can radical cystectomy and antiandrogen therapy cure the disease?]. / Das duktale Adenokarzinom der Prostata mit Blasenhalsinfiltration. Heilung durch radikale Zystektomie und antiandrogene Therapie?

Ductal adenocarcinoma of the prostate is a rare entity. The lack of correlation between the prostate-specific antigen value and the tumor stage, as well as early dissemination, are major differences from acinar cancer. Due to a lack of early symptoms, the tumor is often found in an advanced stage. Urinary obstruction and hematuria lead to clinical assessment. The characteristic tumor growth near the seminal colliculus can yield a negative digital rectal examination. Despite a lack of treatment guidelines, authors recommend an aggressive surgical concept. First approaches include radical prostatectomy, transurethral resection, and high-dose radiotherapy. Subsequent androgen deprivation is recommended. We report the case of a 64-year-old man with ductal prostate cancer who underwent radical cystectomy followed by androgen deprivation therapy. This is the first such case reported in both the German and the English literature.

Functional magnetic resonance imaging and cortical mapping in motor cortex tumor surgery: complementary methods.

Functional magnetic resonance imaging (fMRI) and direct electrocortical stimulation (DES) are the most commonly used means of analyzing the functional brain topography prior to surgery in the vicinity of Brodmann area 4. No consensus has been established in the literature about the significance of both procedures in reducing operative morbidity. The study presented here was conducted in 30 patients with tumors in the area of the primary motor cortex. Blood oxygen level dependent (BOLD) sequences were preoperatively established with a standardized paradigm. Intraoperatively motor mapping was performed with DES. The results of both methods were digitally matched with a frameless image-guidance system. Correlations between the results of fMRI and of DES were analyzed. Furthermore, the potential influences of the size, position, and histology of the lesions on the mapping results were analyzed and the motor outcome was evaluated. The mean deviation between the results of fMRI and of DES was 13.8 mm (range: 7-28 mm). This deviation was independent of the histology, size, or location of the corresponding lesion. The individual variability of the analysis threshold value for the evaluation of the BOLD sequences led to a considerable topographical inaccuracy. As complementary methods, fMRI contributes to estimating the operational risk, while DES is performed when the results of MRI and fMRI suggest an immediate proximity of the tumor to motor areas.

Debridement and spinal instrumentation as a single-stage procedure in bacterial spondylitis/spondylodiscitis.

OBJECT: The best surgical technique for patients with bacterial spinal infections is still discussed controversially. But recent publications suggest that titanium implants can be used safely in infectious sites in combination with debridement and antibiotic therapy. The purpose of this study is to provide further evidence in support of debridement and instrumentation as a single-stage procedure for spinal infection. METHODS: Twenty-four cases with cervical, thoracic, and lumbar spondylitis/spondylodiscitis were analyzed. In 17 cases, anterolateral stabilization was performed with titanium cages. No autologous or homologous bone grafts were used. Transpedicular screw/rod fixation following posterior debridement of the intervertebral space was performed in the other 7 cases. RESULTS: WBC and C-reactive protein levels decreased significantly after surgical debridement. Pain levels decreased from a preoperative median of 4 (on the Denis Pain Scale) to a postoperative median of 2. Twenty-two of the 24 patients were fully mobilized within 2 weeks after surgery. The Barthel Index improved from 60 (10-85) before surgery to 90 (65-100) after surgery. No recurrence of the initial infection was noticed during a mean follow-up period of 18 months. The fusion rate was 90.5%. The mortality rate was 1 out of 24 (4.2%). CONCLUSIONS: These findings support the position that debridement and instrumented fusion can be performed as a single-stage procedure without an increase in the recurrence rate or morbidity, compared with the use of autologous bone grafting or staged procedures. Same-stage instrumentation allows early postoperative mobilization of the patient, which is advantageous, especially for an increasingly elderly population and in patients with comorbidities.

Atypical location of a solitary intracranial chondroma without meningeal attachment.

The case of a 19-year-old female patient with a history of severe headache for several months is presented. Computed tomography (CT) as well as magnetic resonance imaging (MRI) revealed an intracranial, space-occupying mass with no meningeal attachment, located in the left frontal lobe. The entire tumour was removed, the pathological examination revealed a chondroma. The origin of this tumour is analysed, the clinical and histological findings are described and the literature is reviewed.

Scaphoid bone bruising--probably not the precursor of asymptomatic non-union of the scaphoid.

The MRI finding of bone marrow oedema, without fracture, following trauma to the scaphoid has been called a 'bone bruise'. A similar injury is found in the knee, considered benign and managed conservatively. In the scaphoid, there is the concern that this lesion may lead to scaphoid non-union. This study addresses that concern. The clinical and radiological findings of 41 patients with a scaphoid bone bruise on MRI are described, an MRI classification system proposed and clinical outcomes investigated. Patients were immobilised for 6 weeks. At 3 months, 8 remained symptomatic and had repeat MRI. Four of these showed complete resolution of the bruise, the others improvement. At 6 months, 2 of the 8 complained of minor, intermittent discomfort but progressed to resolution of symptoms. This study suggests that the scaphoid bone bruise is a benign injury with predictable recovery and is unlikely to result in long-term morbidity in the form of non-union.

Injection therapy of lumbar facet syndrome: a prospective study.

BACKGROUND: Chronic low back pain remains a major health problem. Facet joint injection therapy is an easy to perform therapeutic option. However, few prospective studies use a standardized protocol to investigate injection therapy. The aim of our study was to evaluate quantity and duration of clinical improvement after this protocol, and to identify the best time for additional repetitive injection therapy. MATERIALS AND METHODS: Thirty-nine patients (21 men, 18 women; mean age 55.2 years [range, 29-87 years]) with lumbar facet syndrome were treated with injection using a standardized protocol (prednisolone acetate, lidocaine 1%, phenol 5%) under fluoroscopic control. Follow-up was based on a specially designed questionnaire. Analysis included MacNab criteria, visual analogue scale, and pain disability index. RESULTS: Reduction of pain was found up to 6 months after treatment. The outcome was assessed excellent or good by 62% (24 patients) of the patients after 1 month, by 41% (16 patients) after 3 months, and by 36% (14 patients) after 6 months. There was no influence of age, body mass index, or previous lumbar spinal surgery on improvement after treatment. There were no severe side effects. Short-lasting self limiting mild side effects were found in 26% (increased back pain, numbness, heartburn, headache, allergy). CONCLUSION: Facet joint injection therapy using a standardized protocol is safe, effective, and easy to perform. The clinical effect is limited, and we recommend repetitive injection according to this protocol after 3 months.

Multimodal protocol for awake craniotomy in language cortex tumour surgery.

BACKGROUND: Intra-operative neurophysiological language mapping has become an established procedure in patients operated on for tumours in the area of the language cortex. Awake cranial surgery has specific risks and patients are exposed to an increased physical and mental stress. The aim of the study was to establish an algorithm that enables tailoring the neurosurgical and anaesthetic techniques to the individual patient. METHOD: A total of 25 patients underwent awake craniotomy for intra-operative language mapping between 1999 and 2004. Following craniotomy under analgesia and sedation without rigid pin fixation of the head, cortical language mapping was performed in the fully co-operative patient. The results of functional magnetic resonance imaging and of cortical language mapping were incorporated into the 3D dataset for neuronavigation. Depending on the functional data and the individual operative risk tumour resection then proceeded either under conscious sedation with the option of subcortical language monitoring or under general anaesthesia. FINDINGS: After cortical language mapping patients are assigned to one of four groups: BACC (Berlin awake craniotomy criteria) I-IV. BACC I (9 patients): adequate functional data+operative risk not increased-->tumour resection in the awake patient; BACC II (4 patients): limited functional data+operative risk not increased-->tumour resection in the awake patient with the option of language monitoring as needed; BACC III (9 patients): adequate functional data+increased operative risk-->tumour resection under general anaesthesia using functional navigation; BACC IV (3 patients): limited functional data+increased operative risk-->tumour resection in the awake patient with the option of language monitoring as needed. We observed less adverse events in group BACC III. No permanent deterioration of language function occurred in this series. CONCLUSIONS: The multimodal protocol for awake craniotomy provides for tumour resection under general anaesthesia in selected patients using functional neuronavigation. Our experience with the algorithm suggests that it is a useful tool for preserving function in patients undergoing surgery of the language cortex while reducing the operative risk on an individual basis.

Motor nerve root monitoring during percutaneous transforaminal endoscopic sequestrectomy under general anesthesia for intra- and extraforaminal lumbar disc herniation.

INTRODUCTION: Percutaneous transforaminal endoscopic sequestrectomy (PTFES) for intra- and extraforaminal lumbar disc herniation (IHLD and EHLD) is usually performed under local anesthesia because the patient's full cooperation is necessary during surgery in order to reduce morbidity. This puts intraoperative stress on both the patient and the surgeon. The present study was performed to assess the safety and efficacy of performing PTFES under general anesthesia using a new protocol with continuous intraoperative neurophysiological monitoring (IOM). PATIENTS AND METHODS: Twenty-five patients with IHLD and/or EHLD were treated by PTFES under general anesthesia without neuromuscular blocking agents. Free-run electromyography (EMG) recordings from characteristic muscles were monitored for the nerve root exiting through the intervertebral foramen at the level of surgery as well as those immediately above and below this level. The recorded potentials were visualized and analyzed on the monitoring screen. Additionally, the EMG activity was played to the surgeon via loudspeakers. RESULTS: EMG-assisted endoscopic sequestrectomy was successfully completed in all 25 cases. Three patients showed complex repetitive discharge patterns already before the actual procedure, but these normalized upon removal of the sequester. Abnormal EMG changes in the form of intraoperative isolated spikes, phasic bursts, or tonic trains were recorded in 17 of the 25 cases. These occurred during placement of the endoscopic working channel in the area of the neuroforamen in 12 cases and during removal of the sequester in 6 cases. Spikes and bursts were evoked by direct contact with the nerve root or indirectly through traction or compression. Tonic discharge patterns, on the other hand, correlated with more severe mechanical stress caused for instance by compression or traction when the nerve root was fixed in the neuroforamen by the sequester. CONCLUSIONS: PTFES under general anesthesia is a safe and easy-to-perform technique for surgical management of intra- and/or extraforaminal lumbar disc herniation if combined with intraoperative neurophysiological monitoring. General anesthesia reduces intraoperative stress to a minimum, so that a larger number of patients may benefit from this minimally invasive procedure in future.

[Sensor-based detection of skull positioning for image-guided cranial navigation under free head mobility]. / Sensorbasierte Schädelreferenzierung für die schnittbildgeführte Navigation unter freier Kopfbewegung.

PURPOSE: Although computer- and image-guided surgical procedures are an improvement of frame-guided stereotaxy, many navigation systems still require rigid fixation of the patient's head throughout the operation. This study describes the clinical application of a technical modification that enables cranial navigation with "free head mobility" using CT and MR images as well as the calculated 3-D reconstruction models. MATERIAL AND METHODS: A sensor-based electromagnetic neuronavigation system was expanded to allow the localization and position monitoring of several sensors within an electromagnetic field. One of these sensors was attached to a dental splint as an additional reference (DRF = dynamic reference frame). Thus, it was possible to determine the position of the sensor-guiding surgical instruments and to record the slightest movement of the cranium as well. This information was then used to continuously adapt the position of the imaging plane and the resultant calculated 3-D reconstructions to the actual position of the cranium. RESULTS: The clinical application of the DRF was tested for different neurosurgical procedures. They included image-guided biopsies and endoscopic interventions using MRI data, transnasal accesses to the base of the skull using CT data and surgical removal of multilocular metastases using data from both imaging modalities. Intracranial target reference points as well as those on the skull were found with a high accuracy to the initial measurement position after arbitrary movement of the patient's head. Thus, navigation was also possible without rigid fixation of the head because of the continuous adaptation of the imaging data on the change in position of the patient's head. CONCLUSION: Based on these first test results, a high clinical potential for DRF application in cranial navigation is to be expected. The aim of DRF is to dispense with the rigid fixation of the patient's head. This increases the application scope of image-guided navigation procedures to include, for example, any bioptic or endoscopic intervention, in which rigid pin fixation of the cranium is not required or desired. For all other procedures, continuous position monitoring by DRF ensures automatic correction of imaging data with mechanical alteration of the head position.