Spindle cell oncocytoma of the neurohypophysis with metastasis to the sphenoparietal sinus and immunohistochemical negativity for S100 and epithelial membrane antigen (EMA).

We report the case of a 61-year-old male with spindle cell oncocytoma of the hypophysis. On presentation to the Department of Neurosurgery at the German Armed Forces Hospital of Ulm, the patient reported a history of several years of left sixth nerve palsy, right ptosis, increased sensitivity to light, and a bilateral retrobulbar pressure sensation. Pituitary function was normal. A chromophobe non-functioning pituitary adenoma was initially suspected. The diagnosis was established on the basis of examination at a histopathology reference laboratory using immunohistochemistry to identify cell surface markers. During two years of follow-up, there were two clinical recurrences requiring surgery. To our knowledge, this is the 35th documented case of spindle cell oncocytoma of the pituitary gland and the first that was immunohistochemically negative for epithelial membrane antigen (EMA) and S100; and the first that displayed haematogenous metastasis to the right sphenoparietal sinus. The three surgical procedures were associated with massive intraoperative bleeding and thus resulted in subtotal tumor resection. Following surgery for the recurrences, the patient underwent radiotherapy.

Multifocal and hormone-dependent epithelioid hemangioendothelioma with osteolysis of the second cervical vertebral body: report of an unprecedented surgical approach by using autologous bone graft.

We report the case of a 28-year-old female patient who complained of extreme neck pain when giving birth to a child. Magnetic resonance imaging (MRI) of the cervical spine demonstrated an osteolytic lesion at the second cervical vertebral body (C2). In this presentation, we highlight a transoral surgical approach in order to prevent instability of this osteolytic lesion. To the best of our knowledge, this is the first time that such a route of access has been described for this tumor entity. A histopathologic examination led to the diagnosis of epithelioid hemangioendothelioma. During a follow-up period of 33 months, the patient had no complaints.

Establishing risk-adjusted quality indicators in surgery using administrative data-an example from neurosurgery.

BACKGROUND: The current draft of the German Hospital Structure Law requires remuneration to incorporate quality indicators. For neurosurgery, several quality indicators have been discussed, such as 30-day readmission, reoperation, or mortality rates; the rates of infections; or the length of stay. When comparing neurosurgical departments regarding these indicators, very heterogeneous patient spectrums complicate benchmarking due to the lack of risk adjustment. OBJECTIVE: In this study, we performed an analysis of quality indicators and possible risk adjustment, based only on administrative data. METHODS: All adult patients that were treated as inpatients for a brain or spinal tumour at our neurosurgical department between 2013 and 2017 were assessed for the abovementioned quality indicators. DRG-related data such as relative weight, PCCL (patient clinical complexity level), ICD-10 major diagnosis category, secondary diagnoses, age and sex were obtained. The age-adjusted Charlson Comorbidity Index (CCI) was calculated. Logistic regression analyses were performed in order to correlate quality indicators with administrative data. RESULTS: Overall, 2623 cases were enrolled into the study. Most patients were treated for glioma (n = 1055, 40.2%). The CCI did not correlate with the quality indicators, whereas PCCL showed a positive correlation with 30-day readmission and reoperation, SSI and nosocomial infection rates. CONCLUSION: All previously discussed quality indicators are easily derived from administrative data. Administrative data alone might not be sufficient for adequate risk adjustment as they do not reflect the endogenous risk of the patient and are influenced by certain complications during inpatient stay. Appropriate concepts for risk adjustment should be compiled on the basis of prospectively designed registry studies.

Spine surgery in the International Security Assistance Force Role 3 combat support hospital in Mazar-e-Sharif, northern Afghanistan, 2007-2014.

OBJECTIVESince 2007, a continuous neurosurgery emergency service has been available in the International Security Assistance Force (ISAF) field hospital in Mazar-e-Sharif (MeS), Afghanistan. The object of this study was to assess the number and range of surgical procedures performed on the spine in the period from 2007 to 2014.METHODSThis is a retrospective analysis of the annual neurosurgical caseload statistics from July 2007 to October 2014 (92 months). The distribution of surgical urgency (emergency, delayed urgency, or elective), patient origin (ISAF, Afghan National Army, or civilian population), and underlying causes of diseases and injuries (penetrating injury, blunt injury/fracture, or degenerative disease) was analyzed. The range and pattern of diagnoses in the neurosurgical outpatient department from 2012 and 2013 were also evaluated.RESULTSA total of 341 patients underwent neurosurgical operations in the period from July 2007 to October 2014. One hundred eighty-eight (55.1%) of the 341 procedures were performed on the spine, and the majority of these surgeries were performed for degenerative diseases (127/188; 67.6%). The proportion of spinal fractures and penetrating injuries (61/188; 32.4%) increased over the study period. These spinal trauma diagnoses accounted for 80% of the cases in which patients had to undergo operations within 12 hours of presentation (n = 70 cases). Spinal surgeries were performed as an emergency in 19.8% of cases, whereas 17.3% of surgeries had delayed urgency and 62.9% were elective procedures. Of the 1026 outpatient consultations documented, 82% were related to spinal issues.CONCLUSIONSCompared to the published numbers of cases from neurosurgery units in the rest of the ISAF area, the field hospital in MeS had a considerably lower number of operations. In addition, MeS had the highest rates of both elective neurosurgical operations and Afghan civilian patients. In comparison with the field hospital in MeS, none of the other ISAF field hospitals showed such a strong concentration of degenerative spinal conditions in their surgical spectrum. Nevertheless, the changing pattern of spine-related diagnoses and surgical therapies in the current conflict represents a challenge for future training and material planning in comparable missions.

Study protocol for a multicenter randomized controlled pilot study on decompressive laparotomy vs. decompressive craniectomy for intractable intracranial pressure after traumatic brain injury: The SCALPEL study.

Introduction: Decompressive craniectomy (DC) is the ultimate intervention to lower intracranial pressure (ICP) following severe traumatic brain injury (TBI). However, this intervention is associated with considerable adverse events and a higher proportion of survivors with poor functional outcomes. Research question: In a multicompartment system ICP is associated with intraabdominal pressure (IAP) due to cerebral venous outflow from the brain. This is the rationale for decompressive laparotomy (DL) to control ICP after TBI as reported by experimental and retrospective clinical data. The safety profile of DL is superior to DC. This study aims to randomly assign patients with intractable high ICP after severe TBI to DL or DC. Material and methods: Among other inclusion criteria, ICP must be above 20 mmHg (1-12 h) despite sedation and all other measures according to current guidelines. The primary outcome is the Extended Glasgow Outcome Scale assessed after twelve months. Further secondary outcome measures are compartmental pressure values, complications, etc. After 20 initial patients, results will be reviewed by the ethics committees and safety monitoring board to decide on the enrolment of 80 additional patients. Results: The study is designed to provide not only high-quality prospective data for the first time on this treatment approach, its two-stage design (20 + 80 pts) also provides maximum patient safety. This protocol conforms with the SPIRIT 2013 Statement. Ethics approval was granted by our but also 5 other university ethics committees (registration 473/18S). Conclusion: Registration was performed prior to study initiation in November 2021 (registration number NCT05115929).

Development and first results of a national databank on care and treatment outcome after traumatic brain injury.

PURPOSE: In absence of comprehensive data collection on traumatic brain injury (TBI), the German Society for Neurosurgery (DGNC) and the German Society for Trauma Surgery (DGU) developed a TBI databank for German-speaking countries. METHODS: From 2016 to 2020, the TBI databank DGNC/DGU was implemented as a module of the TraumaRegister (TR) DGU and tested in a 15-month pilot phase. Since its official launch in 2021, patients from the TR-DGU (intermediate or intensive care unit admission via shock room) with TBI (AIS head ≥ 1) can be enrolled. A data set of > 300 clinical, imaging, and laboratory variables, harmonized with other international TBI data collection structures is documented, and the treatment outcome is evaluated after 6- and 12 months. RESULTS: For this analysis, 318 patients in the TBI databank could be included (median age 58 years; 71% men). Falls were the most common cause of injury (55%), and antithrombotic medication was frequent (28%). Severe or moderate TBI were only present in 55% of patients, while 45% suffered a mild injury. Nevertheless, intracranial pathologies were present in 95% of brain imaging with traumatic subarachnoid hemorrhages (76%) being the most common. Intracranial surgeries were performed in 42% of cases. In-hospital mortality after TBI was 21% and surviving patients could be discharged after a median hospital stay of 11 days. At the 6-and 12 months follow-up, a favorable outcome was achieved by 70% and 90% of the participating TBI patients, respectively. Compared to a European cohort of 2138 TBI patients treated in the ICU between 2014 and 2017, patients in the TBI databank were already older, frailer, fell more commonly at home. CONCLUSION: Within five years, the TBI databank DGNC/DGU of the TR-DGU could be established and is since then prospectively enrolling TBI patients in German-speaking countries. With its large and harmonized data set and a 12-month follow-up, the TBI databank is a unique project in Europe, already allowing comparisons to other data collection structures and indicating a demographic change towards older and frailer TBI patients in Germany.

Three years of neurosurgical experience in a multinational field hospital in northern Afghanistan.

BACKGROUND: Since July 2007, neurosurgical services have been continuously available in a multinational Role 3 field hospital in Mazar-e-Sharif (MeS), Afghanistan. In this paper, we analyse a 3-year neurosurgical caseload experience. METHODS: We retrospectively analysed the neurosurgical caseload at a Role 3 medical treatment facility in northern Afghanistan between October 2007 and October 2010. The cases were divided into acute, urgent and elective procedures and into cranial, spinal, peripheral nerve and miscellaneous surgeries. RESULTS: A total of 190 surgeries were performed. Of these, 50 operations (26.3%) were acute procedures that were conducted to save lives or preserve neurological function. In addition, operations included 47 urgent (24.7%) and 93 elective (49%) procedures. There were 58 cranial surgeries (30.5%), 113 spinal surgeries (59.5%), 11 peripheral nerve surgeries (5.8%), and 8 miscellaneous surgeries (4.2%). Surgical treatment was provided to 13 International Security Assistance Force (ISAF) soldiers (6.8%), 22 members of the Afghan National Security Forces (11.6%), and 155 Afghan civilians (81.6%). CONCLUSIONS: The primary mission of the field hospital is to provide sick, injured or wounded ISAF personnel with medical and surgical care, the outcome of which must correspond to standards prevailing in Germany. Only a very small number of neurosurgical operations performed in MeS met the criteria established by this mission statement and by the modern principles of damage-control wartime surgery. This is completely different from the experience reported by other ISAF nations in eastern and southern Afghanistan.

Arachnoscopy: a special application of spinal intradural endoscopy.

OBJECT: The microsurgical removal of obstructions to CSF flow is the treatment of choice in the surgical management of intradural arachnoid cysts. Cardiac-gated phase-contrast MR imaging is an effective tool for the primary diagnosis and localization of arachnoid cysts. Microsurgery, however, does not lend itself to assessments of further adhesions beyond the borders of the exposed area. The use of a thin endoscope allows surgeons to assess intraoperatively whether the exposure is wide enough. METHODS: Between 2006 and 2010, a single neurosurgeon performed 31 consecutive microsurgical procedures with endoscopic assistance in 28 patients with spinal arachnoid adhesions. A MurphyScope endoscope was used for this purpose. The CSF flow was studied before and after surgery in all patients by using phase-contrast MR imaging in the region of the craniocervical junction, the cervical spine, the thoracic spine, and the lumbar spine. RESULTS: In all 31 procedures, CSF flow obstructions were detected at the level identified by phase-contrast MR imaging. In 29 procedures, image quality was sufficient for an inspection of the adjacent subarachnoid space. In 6 cases, the surgeon detected further adhesions that obstructed CSF flow in the adjacent subarachnoid space that were not visualized with the microscope. In all cases, these adhesions were identified and removed during microsurgery. CONCLUSIONS: Arachnoscopy is a helpful adjunct to microsurgery and can be performed safely and easily. It allows the surgeon to detect further adhesions in the subarachnoid space that would remain undetected by microscopy alone.

Treatment of unresectable skull base meningiomas with somatostatin analogs.

OBJECT: The standard surgical treatment for meningiomas is total resection, but the complete removal of skull base meningiomas can be difficult for several reasons. Thus, the management of certain meningiomas of the skull base--for example, those involving basal vessels and cranial nerves--remains a challenge. In recent reports it has been suggested that somatostatin (SST) administration can cause growth inhibition of unresectable and recurrent meningiomas. The application of SST and its analogs is not routinely integrated into standard treatment strategies for meningiomas, and clinical studies proving growth-inhibiting effects do not exist. The authors report on their experience using octreotide in patients with recurrent or unresectable meningiomas of the skull base. METHODS: Between January 1996 and December 2010, 13 patients harboring a progressive residual meningioma (as indicated by MR imaging criteria) following operative therapy were treated with a monthly injection of the SST analog octreotide (Sandostatin LAR [long-acting repeatable] 30 mg, Novartis). Eight of 13 patients had a meningioma of the skull base and were analyzed in the present study. Postoperative tumor enlargement was documented in all patients on MR images obtained before the initiation of SST therapy. All tumors were benign. No patient received radiation or chemotherapy before treatment with SST. The growth of residual tumor was monitored by MR imaging every 12 months. RESULTS: Three of the 8 patients had undergone surgical treatment once; 3, 2 times; and 2, 3 times. The mean time after the last meningioma operation (before starting SST treatment) and tumor enlargement as indicated by MR imaging criteria was 24 months. A total of 643 monthly cycles of Sandostatin LAR were administered. Five of the 8 patients were on SST continuously and stabilized disease was documented on MR images obtained in these patients during treatment (median 115 months, range 48-180 months). Three of the 8 patients interrupted treatment: after 60 months in 1 case because of tumor progression, after 36 months in 1 case because of side effects, and after 36 months in 1 case because the health insurance company denied cost absorption. CONCLUSIONS: Although no case of tumor regression was detected on MR imaging, the study results indicated that SST analogs can arrest the progression of unresectable or recurrent benign meningiomas of the skull base in some patients. It remains to be determined whether a controlled prospective clinical trial would be useful.

Standard and cardiac-gated phase-contrast magnetic resonance imaging in the clinical course of patients with Chiari malformation Type I.

OBJECT: The causal treatment of Chiari malformation Type I (CM-I) consists of removing the obstruction of CSF flow at the level of the foramen magnum. Cerebrospinal fluid flow can be visualized using dynamic phase-contrast MR imaging. Because there is only a paucity of studies evaluating CSF dynamics in the region of the spinal canal on the basis of preoperative and postoperative measurements, the authors investigated the clinical usefulness of cardiacgated phase-contrast MR imaging in patients with CM-I. METHODS: Ninety patients with CM-I underwent preoperative MR imaging of CSF pulsation. Syringomyelia was present in 59 patients and absent in 31 patients. Phase-contrast MR imaging of the entire CNS was used to investigate 22 patients with CM-I before surgery and after a mean postoperative period of 12 months (median 12 months, range 3-33 months). In addition to the dynamic studies, absolute flow velocities, the extension of the syrinx, and tonsillar descent were also measured. RESULTS: The changes in pulsation were highly significant in the region of the (enlarged) cistern (p = 0.0005). Maximum and minimum velocities (the pulsation amplitude) increased considerably in the region where the syrinx was largest in diameter. The changes of pulsation in these patients were significant in the subarachnoid space in all spinal segments but not in the syrinx itself and in the central canal. CONCLUSIONS: The demonstration of CSF flow pulsation can contribute to assessments of surgical outcomes. The results presented here, however, raise doubts about current theories on the pathogenesis of syringomyelia.

Noninvasive intracranial pressure measurement using infrasonic emissions from the tympanic membrane.

OBJECTIVE: We investigated whether ICP can be assessed by measuring infrasonic emissions from the tympanic membrane. METHODS: An increase in ICP was induced in 22 patients with implanted ICP pressure sensors. ICP waveforms that were obtained invasively and continuously were compared with infrasonic emission waveforms. In addition, the noninvasive method was used in a control group of 14 healthy subjects. RESULTS: In a total of 83 measurements, the changes in ICP that were observed in response to different types of stimulation were detected in the waveforms obtained noninvasively as well as in those acquired invasively. Low ICP was associated with an initial high peak and further peaks with smaller amplitudes. High ICP was associated with a marked decrease in the number of peaks and in the difference between the amplitudes of the initial and last peaks. The assessment of infrasonic emissions, however, does not yet enable us to provide exact figures. CONCLUSION: It is conceivable that the assessment of infrasonic emissions will become suitable both as a screening tool and for the continuous monitoring of ICP in an intensive care environment.

Management of neurotrauma by surgeons and orthopedists in a military operational setting.

There is a considerable discrepancy between the potential demand for neurosurgeons and the actual availability of such specialists not only in civilian settings but even more so in military operational environments. For this reason, the Department of Neurosurgery at the German Armed Forces Hospital in Ulm conducts courses for surgeons and orthopedists on the management of patients with neurotrauma. Twelve such courses have already taken place. Each course lasts 1 week. Participants can expect to gain the theoretical knowledge and practical skills they need to provide initial surgical care for patients with traumatic brain injuries and/or spinal trauma. Surgical techniques are practiced above all in pig and human cadavers. At the end of the course, participants with previous surgical knowledge should be able to independently perform a craniotomy, from the planning of the procedure to the closure of the wound. Former course participants have successfully used their neurosurgical knowledge in countries of deployment where they managed patients during teleconsultation sessions and helped repatriate, or even provided surgical treatment to, patients with traumatic brain injuries. In these situations, it was particularly helpful when the physician deployed abroad and the neurosurgeon in Germany knew each other personally. In the future, efforts will be made to combine telemedicine and neuronavigation in an attempt to further improve direct support for physicians under military deployment conditions.

German military neurosurgery at home and abroad.

For many years, the experience of neurosurgeons from the German Armed Forces was limited to the peacetime care of patients in Germany. In 1995, German military neurosurgeons were deployed abroad for the first time. Since the beginning of the International Security Assistance Force mission, there has been a rapidly increasing number of opportunities for military neurosurgeons to broaden their experience during deployments abroad. Since the first deployment of a neurosurgeon to the German field hospital in Mazar-e-Sharif, Afghanistan, a total of 140 neurosurgical procedures have been performed there. Sixty-four surgeries were performed for cranial or spinal neurotrauma management. During the entire period, only 10 International Security Assistance Force members required acute or urgent neurosurgical interventions. The majority of neurosurgical procedures were performed in Afghan patients who received acute and elective treatment whenever the necessary infrastructure was available in the field hospital. Fifteen patients from the Afghan National Army and Police and 115 local patients underwent neurosurgery. Sixty-two procedures were carried out under acute or urgent conditions, and 78 operations were elective.

In-depth characterization of a long-term, resuscitated model of acute subdural hematoma-induced brain injury.

OBJECTIVE: Acute subdural hematoma (ASDH) is a leading entity in brain injury. Rodent models mostly lack standard intensive care, while large animal models frequently are only short term. Therefore, the authors developed a long-term, resuscitated porcine model of ASDH-induced brain injury and report their findings. METHODS: Anesthetized, mechanically ventilated, and instrumented pigs with human-like coagulation underwent subdural injection of 20 mL of autologous blood and subsequent observation for 54 hours. Continuous bilateral multimodal brain monitoring (intracranial pressure [ICP], cerebral perfusion pressure [CPP], partial pressure of oxygen in brain tissue [PbtO2], and brain temperature) was combined with intermittent neurological assessment (veterinary modified Glasgow Coma Scale [MGCS]), microdialysis, and measurement of plasma protein S100ß, GFAP, neuron-specific enolase [NSE], nitrite+nitrate, and isoprostanes. Fluid resuscitation and continuous intravenous norepinephrine were targeted to maintain CPP at pre-ASDH levels. Immediately postmortem, the brains were taken for macroscopic and histological evaluation, immunohistochemical analysis for nitrotyrosine formation, albumin extravasation, NADPH oxidase 2 (NOX2) and GFAP expression, and quantification of tissue mitochondrial respiration. RESULTS: Nine of 11 pigs survived the complete observation period. While ICP significantly increased after ASDH induction, CPP, PbtO2, and the MGCS score remained unaffected. Blood S100ß levels significantly fell over time, whereas GFAP, NSE, nitrite+nitrate, and isoprostane concentrations were unaltered. Immunohistochemistry showed nitrotyrosine formation, albumin extravasation, NOX2 expression, fibrillary astrogliosis, and microglial activation. CONCLUSIONS: The authors describe a clinically relevant, long-term, resuscitated porcine model of ASDH-induced brain injury. Despite the morphological injury, maintaining CPP and PbtO2 prevented serious neurological dysfunction. This model is suitable for studying therapeutic interventions during hemorrhage-induced acute brain injury with standard brain-targeted intensive care.

Primary Amelanotic CNS Melanoma: Case Report and Literature Review.

Primary malignant melanomas of the central nervous system (CNS) are rarely seen entities in the clinical routine. Primary amelanotic melanomas are even rarer. In our literature review, we found only six case reports of primary amelanotic CNS melanomas. Our case report describes the course of a 71-year-old man with a primary amelanotic CNS melanoma with secondary spread to the spine.

The Hakim programmable valve: reasons for reprogramming failures.

OBJECT: In patients with hydrocephalus, the pressure settings of a Medos Hakim programmable valve may require adjustments even months after implantation. In some cases, however, adjustment proves to be impossible. The object of this study was to illuminate the reasons for reprogramming failures. METHODS: Data pertaining to the authors' experience with programmable valves at their clinic were obtained through retrospective review of patient records from 1992 to 1998 and prospectively collected from 1998 to 2006. Between 1992 and 2006, 585 Medos Hakim programmable valves were implanted at the authors' center, and reprogramming failure was observed in 12 of these 585 cases. The authors investigated and recorded the reasons for reprogramming failure. In cases in which the valves had to be explanted, the valves were returned to the manufacturer for further investigation and the results were recorded. RESULTS: In three of the 12 cases of reprogramming failure, the pressure settings could eventually be adjusted by placing the transmitter upside down against the flow direction. In the remaining nine cases, the valve had to be removed, yielding a rate of valve explantation of approximately 1.5% in this series. In two of these nine cases, the valve was found to be rotated longitudinally along its axis. In two cases the ratchet wheel had become loose and in one the radiopaque marker had become dislodged from the baseplate. Extensive deposits were identified macroscopically and microscopically within four explanted valves. CONCLUSIONS: The reasons for failed reprogramming of Codman Medos Hakim valves as described in this article have not been mentioned in the literature so far. Failure of adjusting the pressure setting is a very rare event in a Medos Hakim programmable valve. The programming and adjustment mechanism appears to be very reliable. Valve replacement was required due to failed reprogramming in only a few cases.

[Clinical and Radiological Results after Anterior Cervical Corpectomy with Cage Fusion - a Retrospective Comparison of PEEK vs. Titanium Cages]. / Implantatassoziierte Komplikationen sowie klinischer und radiologischer Verlauf nach anteriorer zervikaler Korpektomie und Cage-Fusion ­ retrospektiver Vergleich von PEEK- gegen Titan-Cages.

Background Anterior cervical corpectomy and fusion (ACCF) has become a standard procedure for patients with spondylotic myelopathy due to multisegmental stenosis of the cervical canal. Beside the fusion technique using autogenous bone grafts, synthetic cages have been increasingly used in recent years. Published information on the clinical and radiological results of different cage materials for ACCF is still limited. The study presented here is the largest series to date reporting clinical and radiological outcomes and complication rates after one- to three-level ACCF using structural polyetheretherketone (PEEK) or titanium cages augmented by anterior plate-screw osteosynthesis. Materials and Methods Retrospective comparative study on 126 patients after cage ACCF using modular PEEK (n = 101) or distractable titanium (n = 25) cages with a minimum follow-up of 6 months. The numbers of hardware failures and implant-related surgical revisions were determined. The rate of subsidence and fusion and the course of lordotic alignment (segmental and regional Cobb's angles) were analysed. Neck Disability Index (NDI) and European Myelopathy Score (EMS) were assessed. Results Significantly greater number of screw and cage complications were detected in the titanium cage group (36 vs. 7.9 % and 64 vs. 36.6 %, respectively). Non-significant trend to a higher rate of implant related revision rate in the titanium cage group (16 vs. 2.97 %). Significantly greater rate of grade I or II fusion in the PEEK cage group after 6 months (82 vs. 52 %). NDI, EMS and lordotic alignment improved significantly in both groups. There were neither significant differences between the two groups nor significant correlations between these clinico-radiological parameters and the cage material. Partial correlations performed with control of parameters showing inhomogenous distribution (patient age, fusion distance, rate of multilevel corpectomy and the rate of intraoperative segmental overdistraction) showed no significant correlations for any of the clinical or radiological outcome parameters and the complications or revisions to the cage material. Conclusion Cages are a safe and effective alternative to autogenous bone graft for ACCF. A significant improvement in clinical and radiological parameters can be achieved with both titanium and PEEK implants. Significant differences between the two cage material groups or significant correlations of clinico-radiological outcome and cage material were not proven. Moreover there is no evidence in the literature for clinical advantages of one special cage material, to date. Therefore further prospective randomised evaluation of different fusion techniques in ACCF is still necessary.

Pediatric Neurosurgical Care in a German Field Hospital in Afghanistan.

Background and Study Objectives Children are commonly found among the injured in war settings. Prognosis often depends on the presence of brain injury. Not all neurosurgery departments of German Armed Forces hospitals, however, have experience in the care of children with neurosurgical conditions. Against this background, we assessed the group of pediatric neurosurgical patients in a German (Role 3) field hospital in Mazar-e-Sharif, Afghanistan. Patients/Materials and Methods We analyzed the operative logbooks from January 1, 2008, to December 31, 2013, to assess the number of neurosurgical procedures that were performed on children (< 18 years of age) at the field hospital of Mazar-e-Sharif. Results During the study period, 327 neurosurgical procedures were performed at the German field hospital. Of these, 29 (9%) were performed on children. The mean age of the pediatric patients (7 girls and 22 boys) was 11.7 years (median age: 12 years; range: 5-17 years). Only three procedures were performed for conditions other than trauma. Pediatric patients accounted for almost 10% of all patients who underwent neurosurgery during a recent military deployment in Mazar-e-Sharif. This percentage is similar to those reported by other nations. These findings show that a considerable number of children underwent neurosurgical treatment. Conclusions Military planners should be aware that Role 3 medical treatment facilities must provide care for pediatric emergencies and must therefore be staffed and equipped accordingly. For military hospitals at home, this means that the management of pediatric patients is an opportunity for medical personnel to receive important pediatric training that enables them to provide care to children in deployed medical facilities.

Survey on Current Postnatal Surgical Management of Myelomeningocele in Germany.

Background and Study Aims Although postnatal surgery can be regarded as the standard of care for open myelomeningocele (MMC), there is no uniform treatment for this condition in Germany. This study assessed the current situation regarding the management of open MMC, a first and essential step toward the development of standards of practice. Patients and Methods In the second half of 2009, we had sent standardized questionnaires to 139 neurosurgery departments and 73 pediatric surgery departments (number of returned questionnaires: 98 and 62, respectively) to identify the principles of MMC management. Newborns with open MMC are treated in 57 of the neurosurgery departments and in 18 of the pediatric surgery departments. Results Overall, 41 of the 57 neurosurgery departments and 16 of the 18 pediatric surgery departments providing care for newborns with MMC perform MMC closure within 24 hours of delivery. In 52 neurosurgery departments and 15 pediatric surgery departments, infants with spina bifida are delivered by planned cesarean section. The diagnostic investigations performed between the time of caesarean delivery and plastic surgical closure vary from none to magnetic resonance imaging of the spine. The criteria underlying the placement of shunts and the time to plastic surgical closure are highly variable. Conclusions The type of treatment that infants with open MMC receive in Germany differs from institution to institution. Clear and consistent guidelines must be established using an interdisciplinary approach to improve treatment and standardize the care provided by surgical specialists for infants with MMC.