Clinical and radiological results of TLIF surgery with titanium-coated PEEK or uncoated PEEK cages: a prospective single-centre randomised study.

BACKGROUND: A comparison of fusion rates and clinical outcomes of instrumented transforaminal interbody fusion (TLIF) between polyetheretherketone (PEEK) and titanium-coated PEEK (Ti-PEEK) cages is not well documented. METHODS: A single-centre, prospective, randomised study included patients who underwent one-level TLIF between L3-S1 segments. Patients were randomised into one of two groups: TLIF surgery with the PEEK cage and TLIF surgery with the Ti-PEEK cage. Clinical results were measured. All patients were assessed by repeated X-rays and 3D CT scans. Cage integration was assessed using a modified Bridwell classification. The impact of obesity and smoking on fusion quality was also analysed. Patients in both groups were followed up for 2 years. RESULTS: Altogether 87 patients were included in the study: of these 87 patients, 81 (93.1%) completed the 2-year follow-up. A significant improvement in clinical outcome was found in the two measurements scales in both groups (RM: p = 0.257, VAS: p = 0.229). There was an increase in CobbS and CobbL angle in both groups (p = 0.172 for CobbS and p = 0.403for CobbL). Bony fusion was achieved in 37 of 40 (92.5%) patients in the TiPEEK group and 35 of 41 (85.4%) in the PEEK group (p = 0.157). Cage subsided in 2 of 40 patients (5%) in the TiPEEK group and 11 of 41 (26.8%) in the PEEK group (p = 0.007). Body mass index > 30 and smoking were not predictive factors of bony fusion achievement. CONCLUSION: There is no significant advantage of TiPEEK cages over PEEK cages in clinical outcome and fusion rate 2 years after surgery.

Accuracy of EUS and CEH EUS for the diagnosis of pancreatic tumours.

OBJECTIVES: The main objective is to compare the accuracy of EUS and CEH EUS for the diagnosis of pancreatic cancer (PC). The secondary objective is to evaluate the accuracy of EUS FNA and to determine to what extent EUS and CEH EUS findings are affected by endosonographer subjectivity. METHODS: A prospective single-centre study was conducted in patients with pancreatic lesions detected on CT. The patients were examined by EUS, CEH EUS and EUS FNA. The obtained results were compared with the final diagnosis that was based on cytology and further clinical findings and on histopathological findings from subjects who underwent surgery. A second reading of the EUS and CEH EUS images was performed by the endosonographer, who was blinded to clinical data of patients. RESULTS: We examined 116 patients, 73 had a final diagnosis of PC, 14 had NETs and 20 had other tumours. The sensitivity, specificity, NPV, PPV, and accuracy of EUS for diagnosis of PC were 83.1, 62.5, 83.1, 70.7 and 78.6%, for CEH EUS 94.5, 61.7, 84.1, 84 and 84.1% and for EUS FNA 87.6, 91.2, 95.5, 77.5 and 88.8, respectively. The inter-observer agreement for EUS marker of PC was good (κ = 0.75), and that for CEH EUS was average (κ = 0.59 for arterial phase and κ = 0.68 for washout in venous phase). CONCLUSION: CEH EUS is a non-invasive method that allows more accurate identification of PC than EUS. The subjectivity of CEH EUS evaluation is worse than that of EUS but acceptable.

Carotid Endarterectomy and Carotid Artery Stenting in the Light of ICSS and CREST Studies.

OBJECTIVE: We analyzed the results of internal carotid artery (ICA) stenosis treatment at our institution according to the treatment modality-carotid endarterectomy (CEA) vs. carotid artery stenting (CAS). METHODS: During 2003-2015, a total of 1894 procedures were performed for ICA stenosis. CEA was done in 1064 cases and CAS in 830 cases.The primary outcome was disabling stroke (mRS > 2) or myocardial infarction within 30 days of treatment. Secondary outcomes were transitory ischemic attacks (TIAs), minor strokes (stroke without impaired activities of daily living), and any other significant complications. RESULTS: Major mortality and morbidity were divided according to their treatment groups; this reached 0.9% in the CEA and 2.5% in the CAS group (p = 0.007). Minor stroke was recorded at 1.5% and 2.7% in the CEA and CAS groups (p = 0.077), TIAs in 1.0% (CEA) and 4.0% (CAS) (p < 0.001), and any complication in 12.4% (CEA) and 13.0% (CAS) (p = 0.694). CONCLUSIONS: CEA is a safe procedure in patients who meet the correct treatment indications. In all subgroup analyses CEA proved to be equal to or better than CAS. This study supports the idea of CEA being the preferred treatment and CAS being reserved for selected cases only.

Intramedullary ependymoma: long-term outcome after surgery.

BACKGROUND: Overall (OS) and progression-free survival (PFS) of patients undergoing spinal ependymoma resection has been frequently reported. Contrarily, OS and PFS of purely intramedullary ependymomas have not been clearly determined yet. METHODS: The data of 37 patients undergoing resection of an intramedullary ependymoma (IE) from January 2000 to December 2016 were analysed retrospectively. RESULTS: The mean age was 46 years. The male:female ratio was 24:13. The median duration of symptoms was 12 months. Sixty-two per cent of ependymomas were in the cervical, 24% in the thoracic, and 14% in the conus region in our series. The median volume was 1.3 ml. A syrinx was found in 49% and a cyst in 32%. GTR was achieved in 89%, STR in three (8%), and PR in one patient (3%). Median follow-up was 114 months. PFS was 87%, 82%, and 82% at 5, 10, and 15 years, respectively. OS was 97%, 88%, and 63% at 5, 10, and 15 years, respectively. There was a significant difference in PFS depending on the extent of resection and in OS depending on the pre-operative clinical status. There was no significant difference in OS and PFS regarding the other examined influencing factors. CONCLUSION: GTR resection was the most important factor influencing PFS. According to our results OS of IEs is much worse than that of spinal ependymomas. Our analysis confirms that patients with good pre-operative (McCormick grade 1 and 2) clinical status have significantly better OS than patients with McCormick grade 3 and higher.

IDH1/2 Mutation and MGMT Promoter Methylation - the Relevant Survival Predictors in Czech Patients with Brain Gliomas.

Gliomas are a heterogeneous group of tumours varying in prognosis, treatment approach, and overall survival. Recently, novel markers have been identified which are linked to patient prognosis and therapeutic response. Especially the mutation of the enzyme isocitrate dehydrogenase 1 or 2 (IDH1/2) gene and the O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status seem to be the most important predictors of survival. From 2012 to 2015, 94 Czech patients with primary brain tumours were enrolled into the study. The IDH1/2 mutation was detected by denaturing capillary electrophores.The methylation status of the MGMT gene and other 46 genes was revealed by MS-MLPA. In all 94 patients, the clinical data were correlated with molecular markers by Kaplan-Meier analyses and Cox regression model. The MGMT promoter methylation status was established and compared to clinical data. In our study eight different probes were used to elucidate the MGMT methylation status; hypermethylation was proclaimed if four and more probes were positive. This 3 : 5 ratio was tested and confirmed by Kaplan-Meier and Cox analyses. The study confirmed the importance of the IDH1/2 mutation and hypermethylation of the MGMT gene promoter being present in tumour tissue. Both markers are independent positive survival predictors; in the Cox model the IDH hazard ratio was 0.10 and in the case of MGMT methylation it reached 0.32. The methylation analysis of the panel of additional 46 genes did not reveal any other significant epigenetic markers; none of the candidate genes have been confirmed in the Cox regression analyses as an independent prognostic factor.

Carotid endarterectomy and carotid artery stenting: changing paradigm during 10 years in a high-volume centre.

BACKGROUND: We analysed the results of internal carotid artery (ICA) stenosis treatment at our institution over the last 10 years according to treatment modalities (carotid endarterectomy [CEA] vs carotid artery stenting [CAS]). Furthermore, we compared our results of treatment prior to the EVA-3S study being implemented into our practice (2003-2007) and after that (2008-2012). METHOD: During the years 2003-2012, a total of 1,471 procedures were performed for ICA stenosis. CEA was done in 815 cases and CAS in 656 cases. The primary outcome was disabling stroke (mRS > 2) or myocardial infarction (MI) within 30 days after treatment. Secondary outcomes were frequency of transient ischaemic attacks (TIAs), minor strokes (stroke without impaired activities of daily living [ADL]) and any other significant complication. Comparisons of the results before and after 2008 were performed. RESULTS: Major mortality and morbidity were divided according to treatment groups; reached 1.0 % in the CEA group and 3.0 % in the CAS group, p = 0.004. Minor stroke was recorded at 1.8 % and 2.7 % in the CEA and CAS, p = 0.245. TIAs in 1.0 % (CEA) and 4.7 % (CAS), p < 0.001. Any complication in 11.9 % (CEA) and 13.3 % (CAS), p = 0.401. In the overall results (i.e. CEA and CAS together), we found in 2008-2012 a decrease of incidence of TIAs (from 30/840 to 9/631, p = 0.011) and any complications (from 120/840 to 64/631, p = 0.017). CONCLUSIONS: CEA performed in a high-volume centre is a safe procedure in properly indicated patients. In all subgroup analyses, CEA fared better than or at least of equal benefit as CAS. Since 2008, the frequency of TIAs and other complications decreased significantly. This study supports an idea of CEA being the first choice of treatment and CAS being reserved for strictly selected cases, such as re-stenosis after a previous carotid procedure, carotid dissection, ICA stenosis after radiotherapy, previous major neck surgery, contralateral cranial nerve palsy or tandem stenosis.

Surgery of brainstem cavernous malformations.

BACKGROUND: Cavernomas are vascular hamartomas made up of thin-walled, grossly dilated blood vessels lined with endothelium. Between 4 and 35 % (mean 15 %) of cerebral cavernomas are located in the brainstem making resection of these lesions one of the most challenging tasks in neurosurgery. METHODS: Patients with cavernomas within the brainstem or deep supratentorial structures were chosen from our prospectively collected database of operated patients with brain cavernomas. The timespan of treatment was between January 1998 and June 2012. Primary outcome was defined as percentage of patients with favourable outcome (Glasgow Outcome Scale (GOS) 4 or 5) at 1 year. Secondary outcome was defined as operation-related morbidity and mortality (drop at least 1 point on GOS at 1 year). RESULTS: A total of 37 patients underwent surgery. The mean age was 34.7 ± 11.7 years. The male to female ratio was 19:16. Thirty-two patients had a solitary lesion and 12 patients harboured multiple lesions. The Glasgow outcome score 4 or 5 was achieved after 34 operations (89.5 %). The mean follow-up was 39 months. We experienced two early post-operative deaths (5.3 %) and decrease in the Glasgow outcome scale postoperatively in 4 patients (10.5 %). CONCLUSIONS: • Favourable outcome was achieved in 89.5 % of cases. • Although M&M appears to be relatively high, surgery is method of choice for surgically accessible lesion which has bled for the first time due to reported high rebleed rate and high probability of poor outcome after cavernoma rebleed. • Radiosurgery should be reserved for those lesions which are deemed unresectable and where surgical intervention is considered favourable to observation alone.

[The significance of biological intracranial meningioma behaviour for their long-term management]. / Význam biologického chování nitrolebních meningiomu pro jejich dlouhodobý management.

INTRODUCTION: From the histological point of view, most meningiomas are benign tumours. Nevertheless, their recurrence is quite frequent, and identifying the risk factors for recurrent disease is of utmost importance. MATERIAL AND METHODS: Prospective study, patients operated on in the period 2/2008-9/2009. Inclusion criteria for enrolment into the study: age 18-70 years, good health status, and previously untreated solitary intracranial meningioma. Evaluation of clinical, surgical, MRI findings and vascular endothelial growth factor serum levels (prior to procedure, 3 months after, 12 months after, 24 months after procedure and at the time of the last follow-up in 11/2011) was performed. Immunohistochemical analysis of histological samples was carried out. Further treatment (wait and see, redo surgery, treatment with radiation using the Leksell Gamma Knife, external radiotherapy) was recorded in case of a positive follow-up MRI finding (recurrent disease, progression of residual tumour). RESULTS: A total of 50 consecutive patients (34 women and 16 men) were included into the study. Average age at the time of surgery was 59.2 years (range 27-75 years). Radical resection with no residual tumour left was achieved in 35 cases. Histological analysis showed grade I meningioma in 45 cases and grade II (atypical) meningioma in 5 cases. Correlation between E-cadherin expression and recurrent meningioma was proved by immunohistochemical examinations; in the remaining investigations, however, such a correlation was not found. No correlation was detected between the serum vascular endothelial growth factor level and the expression of vascular endothelial growth factor in immunohistochemical investigation. A correlation was found between the expression of vascular endothelial growth factor in immunohistochemical investigation and peritumoural oedema. The tumour recurred in 5 cases. CONCLUSIONS: On the basis of our results as well as literature findings we can conclude that all the patients after meningioma surgery need to be carefully followed for the rest of their life by repeated MRI invetigations.

[Phytoestrogenes in menopause: working mechanisms and clinical results in 28 patients]. / Fytoestrogeny v menopauze: mechanismus úcinku a výsledky lécby v sestave 28 pacientek.

OBJECTIVE: Comparison of phytoestrogen treatment efficacy in menopausal women with and without ability to metabolise phytoestrogens. DESIGN: Clinical trial. SETTING: Department of Obstetrics and Gynaecology, Regional Hospital, Mlada Boleslav. METHODS: 28 menopausal women were treated with phytoestrogens in dose 80 mg daily. Before start and after finishing of treatment urinary concentrations of active metabolite S-equol were measured using ELISA method. Similarly before and after treatment Kupperman's index was measured. Patients with urinary concentrations of S-equol above 1 ng/ml were considered as S-equol producers, remaining patients formed control group. RESULTS: 16 out of 28 women were considered as S-equol producers, remainig 12 as a non-producers. Initial urinary concentrations of S-equol were 0.34 +/- 0.37 ng/ml in producers group and 0.29 +/- 0.30 ng/ml in non-producers. After finishing of therapy urinary concentration of S-equol increased to 10.67 +/- 11.57 ng/ml (p = 0.002) in producers group and 0.34 +/- 0.30 ng/ml (p = 0.701) in non-producers. Kupperman's index values were 23.44 +/- 11.57 in producers group and 17.25 +/- 7.78 in non-producers. After therapy value of Kupperman's index decreased to 14.44 +/- 9.97 (p = 0.003) in producers and to 12.00 +/- 7.18 (p = 0.100) in non-producers. No correlation between improvement in Kupperman's index and urinary concentration of S-equol after therapy was found similarly as between urinary concentration of S-equol before and after therapy in producents group. CONCLUSION: Significant phytoestrogen treatment effect in menopausal women producing S-equol was proven. Testing method for S-equol production introduced by our team togehter with suggested threshold urine concentration level of 1 ng/ml allows precise distinction of producers and non-producers of S-equol and subsequently to predict better treatment effect of phytoestrogens.

[Anterior interbody fusion of the cervical spine with a zero-p spacer: radiographic results with a minimum follow-up of one year in a prospective study]. / Prední mezitelová spondylodéza krcní pátere klecí Zero-P (Prospektivní studie - radiologické výsledky s minimálne rocním sledováním).

PURPOSE OF THE STUDY: The aim of this study was to compare the efficacy of anterior cervical microdiscectomy and fusion carried out using a newly designed interbody spacer with that of a standard cage plate construct in patients with symptomatic cervical spine spodylosis. The comparison was based on radiographic results and fusion rates. MATERIAL: A total number of 113 consecutive patients were enrolled in this prospective study between October 2008 and July 2009. Mono- or bisegmental spondylosis was diagnosed in the patients in whom conservative treatment of cervicobrachial symptoms had had no effect. Patients with myelopathy were not included.. METHODS: All patients underwent standard anterior microdiscectomy (at one or two levels). The novel anchored spacer Zero-P was used in 61 patients (group 1) and, in 52 patients, stabilisation was done using the interbody spacer Cornerstone and dynamic plate Premier (group 2). Lateral radiographic views of the cervical spine were obtained before surgery and at 6 weeks, and then at 3, 6 and 12 months after surgery. During follow-up, the cervical spine sagittal alignment (CobbC), segmental angle of the treated levels (CobbS), amount of segmental collapse and fusion rates were measured. RESULTS: There was no significant difference in CobbC between the two groups during follow- up (p < 0.051). A significant difference in the first two values of CobbS was found (p < 0.001), but next changes in CobbS were without any difference in either group. The mean degree of interspace collapse was without any significant difference between the groups. The fusion rate was significantly higher in group 1 than group 2 nine months after surgery (p = 0.032), but was the same in both groups at 12 months after surgery (p = 1.0). CONCLUSIONS: The anchored spacer Zero-P provides biomechanical stability for the cervical spine similar to the cage and dynamic plate construct. Efforts to improve the cervical stand-alone anterior fusion device and to eliminate disadvantages of plate systems should be studied in larger patient groups with longer follow-ups. Key words: cervical spine, interbody fusion, fusion rate, radiology, stand-alone implant, Zero-P.

Haemorrhage from a radiosurgically treated arteriovenous malformation after its angiographically proven obliteration: a case report.

Small lower-grade Spetzler-Martin arteriovenous malformations (AVMs) are mainly treated by microsurgical resection or stereotactic radiosurgery. The choice of treatment largely depends on the referring centre's preference and the patient's decision. We present here a patient with an AVM repeatedly treated at our Leksell Gamma Knife unit with radiographically confirmed obliteration of the AVM which subsequently began bleeding. This case demonstrates the possibility of late complications in radiosurgically treated AVMs even after their demonstrable obliteration. Meticulous histological examination was performed, proving patency of the AVM nidus. The risk of haemorrhagic complications of radiosurgically removed AVMs despite angiographic proof of their obliteration is, in our view, a cogent argument for preferring surgical resection if the AVM is accessible and for prolonged follow-up after radiosurgical treatment of an AVM.

Ekwall's method in social medicine.

The application of Ekwall's method is of considerable importance not only in medicine but also in social sciences and in all sciences concerned with man where qualitative information is used. The authors developed their own variant of Ekwall's method and used it for the evaluation of results of a survey concerned with children at risk. After an explanation of the essence of the method and principles of its application, the authors explain the variant for possible use in social medicine. An important contribution of this procedure is above all the possibility to evaluate the individual comprehensively according to defined signs and to assess accurately the distribution and also the order of comprehensively evaluated individuals of the investigated group.