Evidence level in the treatment of meningioma with focus on the comparison between surgery versus radiotherapy. A review.

In the majority of cases surgery of intracranial meningioma is the primary treatment option. If tumor regrowth occurs or a tumor remnant is left, radiotherapy or radiosurgery are performed. Purpose of this review is to clarify the question, if evidence based data exists regarding the treatment of meningiomas with special focus on the efficacy of stereotactic radiosurgery/ radiotherapy (SRS/ SRT) compared to surgery. A systematic literature search in the most relevant medical databases was done. Primary studies and systematic review with focus on epidemiologic problems and different therapeutic approaches for the treatment of meningioma were included. Standardized data extraction was performed. A total of 31 publications were included. Information and results in the data published with a surgical focus vary strongly regarding the localization of the meningiomas. No randomized clinical trials or prospective cohort studies could be identified. Comparison between surgical and radiotherapeutic success rates was not clearly possible due to different outcome scales (Simpson grading versus tumor volume reduction) used. Progression free survival was ranging from 77% to 97% (complete surgical resection) and 82% to 97% (surgical resection and additional radiotherapeutical treatment) in publications not differentiating between the location of the meningioma. Although no clear evidence exists that one treatment is better than the other, in symptomatic meningioma surgery is considered to be the primary treatment, if the surgical risk is acceptable. Stereotactic radiosurgery and radiotherapy are reserved to locations (optic sheet, cavernous sinus), where surgical risk is expected to be higher.

[Translaminar fenestration for caudally herniated lumbar discs--a technical note]. / Translaminäre Fensterung bei nach kaudal sequestriertem lumbalem Bandscheibenvorfall--Technische Mitteilung.

Translaminar approaches have been described for lumbar disc herniations which are displaced cranially or laterally into the neuroforamen. This technique provides the advantages of a minimally invasive approach with regard to postoperative instability or partial facet joint resection and avoids a medial arthrectomy. We describe this technique for the first time as an option for a caudally sequestrated disc herniation via a transaxillar sequesterotomy.

Computed tomographic angiography: diagnostic procedure of choice in the management of subarachnoid hemorrhage in the elderly patient?

BACKGROUND: The objective of this study was to establish whether 3D computed tomographic angiography (CTA) can be used to determine further management in patients older than 70 years admitted with acute subarachnoid hemorrhage (SAH). PATIENTS AND METHODS: CTA evaluation included analysis of the source images, image-slice-based multiplanar reconstruction, multi-intensity projection (MIP) and finally 3-dimensional rendering. The location and size of the aneurysm, its precise anatomical morphology and the configuration of the circle of Willis were evaluated. Based on these findings, surgery, endovascular coiling or conservative management was selected. RESULTS: Between October 2001 and June 2005, 44 patients over 70 years of age (38 females, 6 males) were admitted to our neurosurgical department with acute SAH. All patients underwent CTA, and additional 2D digital subtraction angiography (2D-DSA) was performed in 14 patients. Forty-five aneurysms (38 ruptured and 7 unruptured) were diagnosed. Six patients were found to have SAH of unknown origin (no aneurysm on CTA nor 2D-DSA). In 20 patients surgery was performed, in 10 patients endovascular coiling of the aneurysm was carried out, and 12 patients were treated conservatively. The findings on CTA and 2D-DSA could be compared for 26 patients (59%). Correlation between CTA and 2D-DSA was good in 25 of these cases (96%). Glasgow Outcome Scale scores of 4 or 5 were calculated for 37% of the operated patients, 27% of those treated with coils, and 36% of the patients treated conservatively. CONCLUSION: In older patients with degenerative vascular diseases, CTA can replace 2D-DSA in most cases if the image quality is excellent and analysis is performed carefully.

Perioperative complication rate of lumbar disc microsurgery depending on the surgeon's level of training.

AIM: Lumbar disc surgery is one of the procedures performed early in neurosurgical training. Agreement exists concerning the use of microsurgical techniques. With increasing surgical experience the clinical outcome should improve, partly because of a reduction in the complication rate. The aim of this study was to evaluate the correlation between patients' immediate clinical outcome, the perioperative complication rate and the surgeons' level of experience. METHODS: Patients undergoing surgery for lumbar disc herniation between January 1998 and December 2000 were investigated. Exclusion criteria were recurrent disc herniations and spinal stenosis. The surgeons were divided into four groups depending on their neurosurgical experience (group A: < or =2 years, group B >2 to < or =6 years, group C: >6 to < or =10 years, group D: >10 years). Anthropometric data, duration of surgery, early and late surgery-related complications and outcome at discharge were analysed. RESULTS: A total of 1 205 patients (556 females, 649 males) were entered in the study. Six hundred and six of the 1 205 patients were treated by surgeons with < or =6 years of training. Seventy-five patients (6.2%) required re-operation. The re-operation rate was lowest (2.91%) in group A and higher (5.25-9.5%) in the other groups. The intraoperative complication rate was highest (4.75%) in group B and significantly lower (1.1-2.5%) in the other groups. On the other hand, fewer patients in group B had persistent postoperative radicular pain. CONCLUSIONS: The clinical outcome after surgery for lumbar disc herniation does not improve linearly with the surgeon's experience. The intraoperative complication rate is highest between the 3rd and the 6th year of training.

[Pigmented villonodular synovitis involving the thoracic spine: a case report]. / Pigmentierte villonoduläre Synovitis der thorakalen Wirbelsäule - operatives Langzeitergebnis: ein Fallbericht.

Spinal diffuse-type giant cell tumours (also known as pigmented villonodular synovitis [PVNS]) are benign. Their occurrence in the thoracic spine is a very rare entity, nevertheless it should be considered in the differential diagnosis. We report about the case of a 35-year-old male presenting with an osteolytic and expansive mass compressing the spinal cord from C7 to Th2. Surgical resection was performed. Histopathological diagnosis was PVNS. 2 years postoperatively the patient was without pain and fully reintegrated in his previous job as a physician.

[Asynchronous lumbar synovial cysts after surgical resection: a case report]. / Asynchrone Facettgelenks-Zyste nach Facettgelenks-Punktion: eine Falldemonstration.

Lumbar synovial cysts represent a rare condition, they are believed to arise from defects of the joint capsule due to degeneration, trauma, rheumatoid arthritis or spondylosis. The symptom spectrum ranges from neural claudication to neurological deficits. We report the case of a contralateral asynchronous facet joint cyst after surgical resection and review the literature.

[Occult sacral meningocele--a diagnostic challenge]. / Okkulte sakrale Meningozele--eine diagnostische Herausforderung.

Occult sacral meningoceles are a rare causative factor for neural claudication or radiculopathy. Facet joint cysts in the lumbar spine causing similar symptoms are much more frequent. We report the case of a patient with the radiological diagnosis of a facet joint cyst causing neural claudication. During surgery an occult sacral meningocele was diagnosed. In the literature there are only few cases reported. Hence, the findings and important differential diagnoses of cystic epidural lesions in the lumbar spine are discussed.

Treatment of degenerative cervical disc disease with uncoforaminotomy--intermediate clinical outcome.

BACKGROUND: Anterior cervical uncoforaminotomy (uncoforaminotomy) is an operative method intended to preserve the functional motion segment of the cervical spine while removing the underlying pathology. Controversy exists concerning the patients best suited for this treatment modality. Furthermore, no long-term outcome analyses have been published. METHODS: Between November 2002 and June 2004, 96 patients underwent single-level uncoforaminotomy in our neurosurgical department for the treatment of cervical radiculopathy. The patients were divided into three groups: A, soft disc; B, hard disc; C, hard and soft disc. Follow-up was performed 2 years after surgery. Clinical outcome was classified according to Odom et al. and to the cervical Oswestry and 11-point box scales for arm and neck pain. RESULTS: Ninety patients (92%) underwent intermediate follow-up examinations at an average of 33 months after surgery. Forty-nine patients were in group A, 24 in group B, and 17 in group C. At discharge, 98% of those in group A, 96% in group B, and 94% in group C showed excellent or good results. In two patients revision surgery was performed within 4 weeks due to recurrent disc herniation. In one patient revision was carried out due to a subcutaneous hematoma. In group B one case of vertebral artery injury occurred. Additionally in one patient of this group revision surgery was performed due to inadequate decompression of the neural foramen. At follow-up 94% of the patients in group A, 89% in group B, and 87% in group C had excellent or good results. The scores on the cervical Oswestry scale and the 11-point-box scale showed no significant differences among the groups. CONCLUSION: Uncoforaminotomy, especially in patients with soft-disc pathologies, is a good operative method for the treatment of radicular pain.

Computed tomographic angiography in the evaluation of clip placement for intracranial aneurysm.

BACKGROUND: Computed tomographic angiography (CTA) has been shown to reliably detect aneurysms pre-operatively. The aim of this study was to compare the ability of post-operative CTA to detect aneurysmal remnants in connection with clip placement compared with digital subtraction angiography (DSA). Furthermore, special attention was paid to identifying factors influencing the image quality of CTA. METHOD: Between January 2005 and January 2006 a total of 76 patients with intracranial aneurysms were treated in our department. Thirty-two patients with a total of 33 clipped aneurysm were included in this study. All patients underwent CTA and DSA after surgery. Two investigators, each blinded to the classifications of the other, assessed image quality and clip placement. FINDINGS: In three patients aneurysmal remnants could be detected with CTA and DSA. One 2-mm aneurysmal remnant was not clearly identified on CTA; two small (<2-mm) aneurysmal remnants were definitely not seen on CTA. A single titanium clip was used for aneurysmal clipping in 26 patients, two clips were needed in six patients and one aneurysm required three clips being used. Overall, use of one titanium clip tended to result in better image quality. In addition, clip-gantry angles between 30 degrees and 60 degrees tended to yield better image quality. CONCLUSION: Post-operatively, CTA can be recommended as a reliable non-invasive diagnostic tool only with optimal image quality and with this criterion up to 66% of the aneurysms can be evaluated. Titanium artefacts, especially in the important zone (<2 mm) around the clip in which small aneurysmal remnants can occur, can render adequate evaluation impossible. CTA image quality depends on the number of titanium clips used, but clip-gantry-angle does not significantly influence the image quality.

Microsurgically induced aneurysm models in rats, part I: techniques and histological examination.

INTRODUCTION: The percentage of aneurysms treated surgically has steadily decreased since the results of the ISAT study were published in 2002. The aim of this study was to develop different reliable and reproducible aneurysm models for microsurgical training and further research to guarantee effective instruction in microsurgery for young neurosurgeons with comparable aneurysms like in humans. METHODS: Arterial and venous pouch aneurysm models were created microsurgically using 22 Wistar rats. The femoral and the proximal iliac vessels and the bifurcation of the common carotid artery were exposed for induction. For histological examination every aneurysm was dissected out and analysed. RESULTS: A total of 39 microaneurysms was created in three different regions. During the creation four complications occurred: 4 bleedings and 1 defect were observed and immediately treated. Linear regression curves of the microsurgical evaluation showed a significant advancement in the course of the study. The volumes of the different models were: 2.58+/-1.01 mm (3) for the carotid, 6.49+/-3.36 mm (3) for the iliac and 10.41+/-4.13 mm (3) for the femoral aneurysms. The aspect ratios were 1.86+/-0.45 at the iliac, 1.62+/-0.3 at the femoral and 1.21+/-0.29 for the carotid aneurysms. In 89.7% of the cases the aneurysm sac was thrombosed accentuated at the aneurysm tip while the central zone of blood inflow revealed no thrombus formation. The proportion of endothelial cells displayed a reduction in relation to the total number per cross-section in all aneurysm types. CONCLUSIONS: The presented aneurysm models in rats are reliably and immediately available for further training or scientific histological investigations. Despite the fact that these are not bifurcation aneurysms, basic techniques such as suturing and microtechniques used for the dissection and repair of vessels can be taught.

Deep venous thrombosis after lumbar disc surgery due to compression of the vena cava caused by a retroperitoneal haematoma.

The case of a 46-year-old Arabian male complaining of low back pain due to congenital lumbar spinal canal stenosis with additional disc herniation is presented. Following CT scan and MRI, bilateral enlarged partial hemilaminectomy was performed in L5/S1 with removal of herniated disc material. Intraoperatively, no complication was encountered. In the postoperative course, the patient had persistent low back pain and developed deep venous thrombosis in the left leg. Phlebography revealed thrombosis in the deep veins of the left leg extending into the pelvic region. The source of this high obstruction of the venous outflow was a retroperitoneal haematoma, visible on CT scan, compressing the vena cava at the level of L5/S1, the most probable cause of which was accidental perforation of the anterior spinal ligament. This case demonstrates that injury to the retroperitoneal vessels during lumbar disc surgery can also present as deep venous thrombosis due to obstruction of venous outflow.

Current status of intraoperative real-time vibrography in neurosurgery.

PURPOSE: Intracranial lesions are often characterized by different elasticities. The aim of the present study was to test the application of vibrography during brain tumor surgery. MATERIALS AND METHODS: The real-time vibrography system consisted of a conventional ultrasound system (Siemens Sonoline Omnia) with a custom-designed RF interface and a 6.5-MHz endocavity curved array (Siemens 6.5EC10). The RF data were digitized using a 50-MHz, 12-bit PCI analog/digital (A/D) converter for real-time or offline processing. Static compression was replaced by low-frequency axial vibration of the probe. A special applicator equipped with a stepping motor moved the ultrasonic probe and produced a low frequency mechanical vibration of 5-10 Hz with a vibration amplitude of 0.3 mm and slight preliminary compression (total<1 mm). The maximum application time was 60 sec. A pneumatic holding device (Unitrac, Aesculap, Tuttlingen, Germany) was used. RESULTS: Brain tissue is normally color coded between red and orange. In this study 41 out of 45 tumors could be detected via vibrography. Two tumors could not be detected with this imaging technique: a glioblastoma at a depth of 2 cm and a metastasis at a depth of 3 cm. Two additional tumors were not recognized because of technical problems. In 4 cases tumors with strain values identical to those in brain tissue (coded red or orange) but easily identified by a peripheral zone of high strain (yellow) were found. Tumors with strain values higher than those measured in brain tissue coded yellow and were softer than brain during surgical intervention. Higher strain was found in 23 tumors. Tumors with strain values lower than those in cerebral tissue were found to be harder during surgery and coded brown or black. Lower strain was found in 10 cases. Four tumors were inhomogeneous and could not be assigned to one of the above groups. Mortality was 0%, morbidity 2.3%. One patient displayed transient paresis of the lower extremity due to microsurgical difficulties during the approach. In one patient minimal bleeding of the cortical surface occurred in a frontobasal tumor; however, no postoperative deficits were noted. CONCLUSION: Vibrography is a new low-risk technique for intraoperative imaging. In low-grade astrocytomas and oligodendrogliomas, this additional technique can be used to control resection. In other cortical and subcortical tumors (e. g. metastases), it can provide an impression of the intratumoral elasticities.

An optical evaluation of the phenomenon of red out in neuroendoscopic surgery: what is the physical background?

BACKGROUND: The loss of visualization in neuroendoscopy due to intraoperative bleeding is called "red out". Although red out is a well-known problem during endoscopy, clear physical descriptions of this phenomenon are lacking. OBJECTIVE: The aim of this study was to investigate the optical properties of red out. In particular, the attenuation coefficient, comprising scattering, and absorption, of various blood/Ringer solutions was quantified and measured spectrally resolved. Small amounts of blood virtually preclude neuroendoscopic visualization. In blood/Ringer solutions with a dilution of 1:101, it was not possible to distinguish characters (font size 10, Arial) at a distance of 5 mm. We have concluded, from our physical investigations, that the problem of red out is dominated by scattering rather than by absorption. Accordingly, technical developments aimed at increasing information acquisition under red out conditions should be based on optical measurement concepts for scattering media.

Chronic subdural haematoma in patients with Huntington's disease.

We studied the frequency of patients who had chronic subdural haematomas (CSDH) and Huntington's disease (HD) in a 1-year study period. In our department a total of 58 patients with CSDH were treated. Four patients (6.9% of them) had HD. Surgical evacuation of the haematoma was performed in all four cases with the use of a twist drill trepanation without a drainage system.

Anterior uncoforaminotomy in the treatment of recurrent radiculopathy after anterior cervical discectomy with fusion.

BACKGROUND: In patients after anterior cervical discectomy (ACD) with fusion newly developed retrospondylophytes or incomplete decompression of the nerve root can cause recurrent radicular pain. Anterior cervical uncoforaminotomy (uncoforaminotomy) is an operative method which removes the causative degenerative pathology at the level of the neural foramen leaving untouched the inserted graft at this level. METHOD: Between February 2004 and April 2005, 7 patients underwent uncoforaminotomy after ACD with fusion for the treatment of recurrent cervical radiculopathy in our neurosurgical department. Prior to treatment patients received a computed tomography (CT) and a neurological examination. Anterior uncoforaminotomy was performed thereafter (for technical details see publication by Jho, 1996). A postoperative CT scan was done before discharge. Follow-up examination was performed eight weeks after surgery. FINDINGS: Five patients underwent the operation at C5/6, one patient was operated at C6/7 and one patient had the operation at two levels (C5/6 and C6/7). At discharge six patients had excellent or good results. CONCLUSION: Uncoforaminotomy is a good method for the treatment of newly acquired spondylotic spurs in the foramen or incomplete osseous decompression after ACD with fusion and recurrent radicular pain.

3-Dimensional computed tomographic angiography for use of surgery planning in patients with intracranial aneurysms.

BACKGROUND: After subarachnoid haemorrhage (SAH) diagnostic evaluation of the underlying cause is warranted since the rebleeding rate is high. The objective of the study was to answer the question, whether 3-Dimensional computed tomographic angiography (3D-CTA) is able to accurately determine the surgical indications in patients with intracranial aneurysms. METHODS: After performing 3D-CTA the size of the aneurysm, direction of the aneurysmal dome, neck position and variants of the circle of Willis were analysed. Surgery was performed solely on CTA data in those cases, where the aneurysm was clearly visible. If the findings were negative or inconclusive, intra-arterial digital subtraction angiography (DSA) was also done. FINDINGS: Between January 2001 and December 2002 100 patients (68 F, 32 M) were examined and 123 aneurysms (86 ruptured and 37 unruptured) were diagnosed. All patients received CTA preoperatively and in 27 patients selective DSA was additionally performed. Postoperatively in 34 patients the operative result was checked by DSA. A good correlation between CTA and the intra-operative findings was present in 92 of 100 patients. One aneurysm was not seen on CTA, but was on DSA. In four cases we could confirm DSA findings in CTA after re-evaluation of the data. In three cases neither CTA nor DSA clearly showed an aneurysm, but it was confirmed during surgery. A good correlation between CTA and DSA was found in 60 of 61 patients (98%). The correlation between CTA and intra-operative findings was good as expected in 92 patients, in 5 patients an aneurysm was detected on re-evaluation. Only one aneurysm could not be demonstrated by CTA but in DSA. CONCLUSION: CTA is less invasive, less time consuming, cheaper and easier to demonstrate the essential information regarding the aneurysm than DSA. We therefore recommend that following a careful analysis most aneurysms - 92% - can be operated solely on CTA data.

Application of a newly developed visual navigation system in humans. First results.

A visual navigation system (VN) was developed which uses intraoperatively stored endoscopic images together with their specific 3D-address. A special calibration enables one to recalculate the distortion of the endoscopic images. Several modules (e. g., landmark tracking, virtual back-movement) are offered to the neurosurgeon. The system was tested in 12 human subjects during neuroendoscopic interventions and worked without problems in nearly all cases. The possibilities of digital image navigation can be used especially for control of instrument movement in case of red-out situations or blurred vision. Many further developments of the VN system are possible in order to increase the safety of neuroendoscopic interventions.

Consideration of ergonomic aspects in the development of a new endoscopic navigation system.

During the development of new navigation systems, the ergonomic aspects of the accompanying software are seldom taken into account. The VN system is a navigation system working with real and previously stored neuroendoscopic images. The latter enable the module to execute virtual back movement, e.g. in case of bleeding. Several other modules are offered. The aim of the study was the ergonomic analysis of different modules and their learning curves in cadaveric heads. The endoscope was navigated by the neurosurgeon while another person operated the computer. A total of 128 experiments were performed with two software versions. When the landmark tracking module was used, a real learning curve could be observed. By contrast, testing the measurement module did not produce a learning curve. A significant reduction of the time required by the three modules investigated could be observed with software version 2. The module for virtual back movement works best with a minimum time of 20 s for image storage. During machine-human interactions ergonomic software use is important, especially if operative procedures are performed.