Focusing on foot drop: Results from a patient survey and clinical examination.

BACKGROUND: Epidemiological data concerning the symptom 'foot drop' are scarce in the literature. However, everyday practice shows that this symptom is frequent, and that patients who suffer from it are significantly disabled. METHODS: A special 'foot-drop consulting hour' to examine and advise people with foot drop was founded. Over 18 months we collected data from 65 patients who consulted us: this included patient-related items, diagnoses and treatment. RESULTS: People of all ages were affected by foot drop. Left and right sides were affected with equal frequency. Spinal lumbar nerve root damage and peroneal nerve compression were the most frequent causes, followed by polyneuropathy and nerve trauma. In 18% of patients more than one pathological condition was found that might have led to foot drop. In 14% no reason could be determined. 45% of patients with foot drop subsequently received surgical treatment. CONCLUSION: Epidemiological data and details of patients affected by foot drop can help to raise awareness of this frequent symptom and to suggest specific therapy.

High accuracy of external ventricular drainage placement using anatomical landmarks.

BACKGROUND: The conventional approach for external ventricular drainage (EVD) application is the freehand method. Technical devices can improve the accuracy of placement, but they have not yet replaced anatomical landmarks owing to the cost and effort that they entail. There is disagreement as to whether freehand EVD application is safe enough to be accepted as a standard technique. Many authors have investigated the final catheter position in retrospect. They describe variable rates of malpositioning. However, few studies have assessed in how far cranial surface anatomy has really been respected during burr-hole drilling and catheter insertion. The aim of this study was to investigate parameters that might play a part in determining the final intracranial catheter position. METHODS: In all, 100 pre- and postprocedural thin-layer computed-tomography (CT) scans of EVD patients were analysed with the help of JiveX® and OsiriX Lite® software. A series of anatomical and catheter-related parameters, including inter alia intraventricular blood, midline shift, burr-hole location and catheter entrance angle, were correlated with the final catheter position. RESULTS: A majority of EVDs show an optimal or nearly optimal position. Only the deviation of catheter entrance angle has a significant influence on catheter malpositioning. The burr-hole location can vary within an area of several centimetres around the coronary suture. CONCLUSIONS: The freehand application of EVD is safe as long as the intracranial anatomy is not disfigured to a large extent, the surface measurements are carried out precisely and the puncturing is done perpendicularly to the skull.

Use of processed bovine pericard in peripheral nerve surgery.

OBJECTIVE: Nerve damage often means a loss of the epi- and perineural sheaths, an adherence to the surrounding tissue and a loss of smooth movements. This leads to pain and functional deficits. Creating a gliding apparatus for damaged nerves is a possibility to restore physiological function and interrupt the vicious circle of pain. PATIENTS AND METHODS: We investigated nine patients who were undergoing peripheral nerve surgery in the forearm and upper arm region. Surgeries included six revisions due to scar-adherence caused by bone fracture surgery, two revisions due to previous nerve compression syndrome surgery and one revision after complete severing of the nerve and previous emergency surgery of the vessels. In each case, the nerve was freed from enveloping scar tissue and a processed bovine pericard (Tutopatch®) was used to wrap or cover parts of the affected nerve. The patients were examined clinically and by high-resolution sonography (HRS) after surgery. RESULTS: All patients showed improvement in respect of function and of pain. There were no adverse reactions as a consequence of the material used. HRS showed that the Tutopatch melds with its environment, and it did not lead to re-scarring of the nerve. CONCLUSION: Tutopatch appears to be a suitable allogeneic material for nerve-wrapping.

Development of a brain simulator for intracranial targeting: Technical note.

Learning and enhancing of manual skills in the field of neurosurgery requires an intensive training which can be maintained by using virtual reality (VR)-based or physical model (PM)-based simulators. However, both simulator types are limited to one specific intracranial procedure, e.g. the application of an external ventricular drainage (EVD), and they do not provide any accuracy verification. We present a brain simulator which consists of a 3D human skull model having five electroconductive balls in its interior. The installed balls represent intracranial target points providing various accuracy problems in neuronavigation. They are electrically contacted to lamps getting an optical signal by touching them with a current-carrying target tool. The simulator fulfills two requirements: First, it can prove the accuracy of navigation systems and algorithms. Second, it allows becoming familiar with a navigation system's application in an ex vivo setting. It could be a helpful device in neurosurgical skills labs.

One-step CAD/CAM titanium cranioplasty after drilling template-assisted resection of intraosseous skull base meningioma: technical note.

INTRODUCTION: Cranial defects following intra-osseous tumor removal may be large and require adequate reconstruction. CAD/CAM implants have been used for years to achieve an optimal cosmetic result. The disadvantage is that such implants require a second surgery. A preoperative virtual planning of resection margins and the simultaneously fabrication of the cranioplasty could be a possibility to subsume the steps tumor resection and cosmetic restoration to a single procedure. METHODS: We present two cases of patients with complex intra-osseous spheno-orbital meningioma. Tumor resection was performed with the help of a drilling template in form of a frame. The template also served as a negative for the computer-designed cranioplasty. The devices were manufactured by DMD GmbH - Digital Medical Design/DDI-Group, Dortmund, Germany. DISCUSSION: The usage of the template was highly practicable. Small adjustments in bone removal were necessary to achieve an optimal fitting of the implant. The 6-month follow-up showed for one patient a good and for one a satisfactory cosmetic result. No second surgery was necessary. CONCLUSIONS: Drilling template application could contribute to challenging cases of large fronto-basal meningiomas with the aim of minimizing operation time and achieving a good esthetic outcome.

Single-center experience in the endovascular treatment of wide-necked intracranial aneurysms with a bridging intra-/extra-aneurysm implant (pCONus).

PURPOSE: To retrospectively evaluate the safety and efficacy of the endovascular treatment of wide-necked intracranial aneurysms assisted by a novel intra-/extra-aneurysm stent-like implant (pCONus). METHODS: Initial and follow-up angiographic and clinical results are presented of 25 patients with 25 unruptured and ruptured wide-necked intracranial aneurysms treated by reconstruction of the aneurysm neck using the pCONus implant followed by coil occlusion of the fundus. RESULTS: Successful intra-/extra-aneurysm deployment of the pCONus with coil occlusion of the fundus was achieved in all but one case. Procedure-related ischemic complications were observed in three cases with permanent deterioration in one. Acceptable aneurysm occlusion was achieved in all cases. Follow-up angiography revealed sufficient occlusion in 81.0% of the aneurysms. Intimal hyperplasia in the stented segment of the parent artery or device migration has not been observed to date. CONCLUSIONS: The pCONus device offers a promising treatment option for complex wide-necked bifurcation intracranial aneurysms. Acute or delayed dislocations of coils into the parent artery are successfully avoided.

Charlson comorbidity index: an additional prognostic parameter for preoperative glioblastoma patient stratification.

PURPOSE: Dismal glioblastoma (GB) patient outcome calls for the elucidation of further reliable predictors of prognosis. Established "biomarkers," age and functional status, employed in today's patient stratification have limits in fingerprinting this heterogeneous tumor entity. We aimed at ascertaining additional prognostic factors that may facilitate patient stratification for surgery. METHODS: A retrospective review of 233 consecutive adult patients operated on for newly diagnosed GB at a single tertiary institution over a 5-year period (2006-2011) was conducted. Modern defined outcome associating factors recorded included demographics (preoperative age, gender, signs, symptoms, comorbidity status quantified by the Charlson comorbidity index (CCI), functional status computed by the Karnofsky performance scale (KPS)), tumor characteristics (size, location, isocitrate dehydrogenase mutation, and O-6-methylguanine-DNA methyltransferase promoter methylation status), and treatment parameters (volumetrically quantified extent of resection and adjuvant therapy). Survival analysis was performed by the Kaplan-Maier method. Influence of variables was evaluated using log-rank test. RESULTS: Median neuroradiographic evidence of tumor progression was 6 months after surgery (range 0-72). The median overall survival was 9.5 months (range 0-72). Age > 65 years, KPS ≤ 70, and CCI > 3 were significantly associated with both poor OS (each p < 0.0001) and PFS (p < 0.0001, p < 0.001 and p < 0.002), respectively. Also, patients older than 65 years significantly had a CCI > 3 (p < 0.0001). CONCLUSIONS: Our data evidence that aside established prognostic parameters (age and KPS) for GB patient outcome, the CCI additionally significantly impacts outcome and may be employed for preoperative patient stratification.

Intracerebral haemorrhage in a population-based stroke registry (LuSSt): incidence, aetiology, functional outcome and mortality.

Data on incidence of intracerebral haemorrhage (ICH) vary widely. Population-based data on predictors of ICH survival and functional outcome are rare. The Ludwigshafen Stroke Study is a prospective, population-based stroke registry which started in January 2006. All residents of the city of Ludwigshafen, Germany, who suffer from acute stroke or transient ischaemic attack are registered. Patients with first-ever primary intracerebral haemorrhage (FE-pICH) between 2006 and 2010 were included in the present analysis. Between January 1st, 2006 and December 31st, 2010, 152 patients suffered a FE-pICH. Crude and age-adjusted incidence rates per 100,000 for FE-pICH were 18.7 (95 % CI 15.9-21.9) and 11.9 (95 % CI 10.2-14.0), respectively, and remained stable over time. Case-fatality rates for FE-pICH were 27.0, 34.9 and 44.1 % at days 28, 90 and 365, respectively. In 21 patients, an (21.3 %) early do-not resuscitate-order was documented. Excluding these patients from multivariate analyses, National Institute of Health Stroke Scale (NIHSS) (OR 1.22, 95 % CI 1.08-1.36), hypercholesterolemia (OR 0.16, 95 % CI 0.05-0.55) and modified Rankin Scale (mRS) prior to stroke (OR 1.56, 95 % CI 1.06-2.3) were independently associated with risk of 1-year mortality, whereas NIHSS (OR 1.41, 95 % CI 1.20-1.66) and leukocyte count on admission (OR 1.48, 95 % CI 1.16-1.89) were independently associated with good or moderate functional outcome (mRS ≤ 3) after 1 year. Incidence of FE-ICH is in the lower range of those reported from other registries and remained stable over the observation period. Higher treatment rates for hypertension might partly account for this. Stroke severity as indicated by NIHSS was independently associated with mortality and functional outcome after 1 year. We found no association between aetiology and outcome in ICH patients.

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.

Neurosurgical operations with the patient in sitting position: analysis of risk factors using transcranial Doppler sonography.

BACKGROUND: One major risk factor of the sitting position for neurosurgery is air embolism, especially in patients with persistent foramen ovale (PFO). The first aim of this prospective study was to evaluate a bedside method for detecting PFO using transcranial Doppler sonography (TCD) with contrast medium. A second aim was to address intraoperative monitoring, patient positioning and the occurrence and clinical relevance of air embolism. METHODS: Ninety patients with a mean age of 56.5 yr (range 14-81 yr) undergoing surgery in sitting position were investigated by TCD with contrast agent to detect functional PFO, that is PFO that can be provoked with a Valsalva manoeuvre. In patients in whom TCD was not possible, transcranial duplex sonography, duplex sonography of the carotid artery at the neck or transoesophageal ECG was performed. RESULTS: In 26 patients PFO was detected. Thirteen of them presented a persistent PFO with high-intensity transient signal in both middle cerebral arteries without Valsalva manoeuvre. The intraoperative positioning in these patients was adapted to the risk for a paradoxical air embolism, although, after surgical recommendations, three patients with a persistent PFO underwent surgery in sitting position. Intraoperative air embolisms were seen in 8 of 80 patients in sitting or semi-sitting position with air aspirable through the central venous catheter. CONCLUSION: To address the risk of a paradoxical air embolism, especially in patients undergoing surgery in sitting position, preoperative detection of PFO is advisable. If surgery is performed in seated PFO patients, additional monitoring and special care are warranted.

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.

[Pain reduction after cervical spine surgery. Outcome after implantation of a cervical wing cage in degenerative diseases of the cervical spine--a prospective study]. / Schmerzreduktion nach Operation an der Halswirbelsäule. Ergebnisse nach Implantation eines zervikalen Wing-Cages bei degenerativen Halswirbelsäulenerkrankungen -- eine prospektive Untersuchung.

AIM: Surgery in cervical spine disease using titanium cages is a common procedure to reduce the pain and neurological deficits. This study was aimed to evaluate the results in pain reduction using the wing cage intraoperatively. METHOD: In this prospective study demographic data were noted, whereas special emphasis was placed on pain, which was noted using a visual pain scale and the prolo score, neurological deficits and the causing pathology. Furthermore, questions about the use of analgesics and the duration of pain were asked. After operation with insertion of a wing cage instead of the disk, a neurological investigation 6, 12 and 24 months later was done to evaluate the postoperative status. RESULTS: 54 patients underwent a cervical discectomy in 64 segments as therapy for neck pain or a radiculopathy caused by osteochondrosis or disc disorder. Patients with brachialgia profited most from the operation. Less improvement was seen in cases of osteochondrosis or combined pathology. CONCLUSION: Patients with pain caused by discs in the cervical spine, have better improvement than patients with other pathologies. This should be taken into account when choosing the mode of therapy.