Retrospective Investigation of Cranial Volume and Cephalic Index in Patients with Nonsyndromic Sagittal Synostosis Operated by Total Vault Remodeling.

BACKGROUND: Premature fusion of cranial sutures affects skull development and leads to head deformity. Intracranial pressure increase and brain growth restriction can occur in untreated craniosynostosis. Operative treatment aims to achieve an immediate and long-lasting correction of skull shape that is close to the average and to prevent or release possible increased intracranial pressure by increasing the intracranial volume (ICV) or normalizing the ICV if it is already below the standards. This study was designed to evaluate the effect of a total calvarial reconstruction on skull development in patients with nonsyndromic sagittal synostosis. MATERIAL AND METHODS: The study population included 19 male and 5 female patients with isolated nonsyndromic sagittal suture synostosis. During the operation, temporarily fixed prebent metal plates provided an intraoperative reference for the desired cranial expansion gain of height and shortening. Preoperative and postoperative ICVs and cephalic indices were measured on computed tomography datasets using the software program ImageJ and were compared with one another and with normative data. RESULTS: The male population presented with a preoperative mean ICV of 863.3 cm³. A postoperative mean ICV increase of 243.5 cm³ (p < 0.001) and a further ICV enlargement (p < 0.001) was measured. The mean CI changed from 71.0% preoperatively to 75.4% postoperatively (p = 0.002) and decreased insignificantly in the follow-up (p = 0.546). The female population had a preoperative mean ICV of 804.9 cm³. Postoperatively, the mean ICV increased by 211.1 cm³ (p = 0.043) and also increased in the follow-up (p = 0.043). Their mean CI values increased from 66.5% preoperatively to 72.8% (p = 0.043) postoperatively and decreased insignificantly in the follow-up (p = 0.345). CONCLUSION: This method of total vault remodeling provides reliable ICV increase and improvement in length and width of skull proportions beyond the immediate postoperative period together with an ICV increase.

Eleven years' experience with Intrathecal Baclofen - Complications, risk factors.

Objective: Treatment with intrathecal baclofen (ITB) is commonly used in patients with severe spasticity. However, complications may occur after implantation of the ITB-device, albeit mainly procedure- and device-related problems. The aim of the study was to assess surgical- as well as catheter- and pump-related complications and define their risk factors. Methods: We retrospectively evaluated all patients with an implanted ITB-device who were treated at the Department of Neurology, Hochzirl Hospital, Zirl, Austria, between 2006 and 2016. Results: Twenty-nine of 116 (25%) patients experienced 32 complications: 5 procedure- and 27 device-related (4 pump- and 23 catheter-associated) problems occurred. Risk factors for sustaining any complication were a spinal localization of lesion (odds ratio [OR] OR 2.71, p = .021), other catheter types than an Ascenda® catheter (OR 3.87, p = .041), a lower modified Rankin Scale (median 4 vs. 5; OR 2.86, p = .015) and a higher Barthel Index (median 53 vs. 0; OR 2.84, p = .006). The median time from the last ITB-related surgery to the first complication was 18 (IQR 1-57) months. Overall, 47% complications occurred within the first year after any surgical procedure regarding the ITB-device, thereof 25% within the first month. Conclusions: Procedure- and device-related complications are frequent after implantation of an ITB-device with catheter-associated complications as the most frequently encountered problems. Patients with a spinal origin of spasticity, a lower modified Rankin Scale and a higher Barthel Index have a higher risk to sustain a complication.

Frameless stereotactic cannulation of the foramen ovale for ablative treatment of trigeminal neuralgia.

OBJECTIVE: Ablative neurosurgical treatment of trigeminal neuralgia, including percutaneous radiofrequency thermocoagulation, requires cannulation of the foramen ovale. To maximize patient security and cannulation success, a frameless stereotactic system was evaluated in a phantom study, a cadaveric study, and a preliminary clinical trial. METHODS: Frameless stereotaxy using an optical navigation system, an aiming device, and a noninvasive vacuum mouthpiece-based registration and patient fixation technique was used for the targeting of a test body based on 1-, 3-, and 5-mm axial computed tomographic slices and of the foramen ovale in three cadavers and 15 patients based on 3-mm axial computed tomographic slices. RESULTS: The mean normal (x/y) localization accuracy/standard deviation (n = 360) was 1.31/0.67 mm (1-mm slices), 1.38/0.65 mm (3-mm slices), and 1.84/0.96 mm (5-mm slices). Significantly better results were achieved with 1- and 3-mm slices when compared with 5-mm slices (P < 0.001). The foramen ovale (3 x 6 mm) was successfully cannulated at the first attempt in all cadavers and patients, which indicates clinical localization accuracies better than 1.5 mm in the anteroposterior and 3 mm in the medial-lateral directions. CONCLUSION: Based on the noninvasive Vogele-Bale-Hohner vacuum mouthpiece, there is no need for invasive head clamp fixation. Imaging, real laboratory simulation, and the actual surgical intervention can be separated in time and location. The presented data suggest that frameless stereotaxy is a predictable and reproducible procedure, which may enhance patient security and cannulation success independent of the surgeon's experience.

Hemispheric brain volume replacement with free latissimus dorsi flap as first step in skull reconstruction.

Large skull defects lead to progressive depression deformities, with resulting neurological deficits. Thus, cranioplasty with various materials is considered the first choice in therapy to restore cerebral function. A 31-year-old female presented with a massive left-sided hemispheric substance defect involving bone and brain tissue. Computed tomography showed a substantial convex defect involving the absence of calvarial bone as well as more than half of the left hemisphere of the brain, with a profound midline shift and a compression of the ventricular system. There was a severe problem due to multiple deep-skin ulcerations at the depression margin, prone to skin perforation with a probability of intracranial infection. In a first step, a free myocutaneous latissimus dorsi flap was transplanted for volume replacement of the hemispheric brain defect, and 4 months later, artificial bone substitute was implanted in order to prevent progressive vault depression deformity. Healing was uneventful, and the patient showed definite neurological improvement postoperatively. Free tissue transfer can be a valuable option in addition to cranioplasty in the treatment of large bony defects of the skull. Besides providing stable coverage for the reconstructed bone or its substitute, it can also serve as a volume replacement.

Intrathecal steroids to reduce pain after lumbar disc surgery: a double-blind, placebo-controlled prospective study.

This double-blind, placebo-controlled prospective study investigated whether corticosteroids (beta-methasone) influence residual radicular pain after lumbar disc surgery. The study population consisted of 26 patients undergoing surgery for a herniated lumbar disc at our University Neurosurgical Department. Thirteen patients received beta-methasone intrathecally prior to wound closure, and 13 patients received normal saline. Main outcome measures were pain intensity graded on a 100-mm visual analogue pain scale (VAS) and consumption of non-steroidal anti-inflammatory agents (NSAIDs). Both patient groups had comparable presurgical findings and pain intensity level (55 mm and 54 mm, respectively, on a 100-mm VAS). After surgery, residual pain declined gradually in the placebo group (mean 39, 29, 24, 20 mm on days 1-4; 10 mm on day 8) and abruptly in the corticosteroid group (mean 15, 15, 11, 8, mm on days 1-4; 5 mm on day 8). Analysis of variance (ANOVA) showed a highly significant influence of time (P < 0.001), a significant influence of steroid application (P = 0.014) and interaction between time and application of steroids (P = 0.042). Mean daily consumption of NSAIDs did not differ significantly in either group: 124 mg in the treatment vs. 150 mg in the placebo group (P > 0.25). At follow-up after 6 months, residual radicular pain was rated equally by both groups (4 mm in the treatment vs. 5 mm in the placebo group, P > 0.5). Intrathecal application of steroids provides short-lasting, significant pain reduction after lumbar disc surgery. Benefits of intrathecal steroids are probably outweighed by the risks associated with violation of the dural barrier.