[Traumatic peripheral nerve lesions : Diagnosis and treatment]. / Traumatische Läsionen peripherer Nerven : Diagnose und Therapie.

Traumatic peripheral nerve lesions affect patients of all age groups. They are associated with functional deficits that have severe consequences for affected patients and prolonged or permanent inability to work has socioeconomic relevance. In order to improve prognoses and achieve the best possible outcome an early diagnosis and competent knowledge of the correct approach and treatment strategies are essential. Unfortunately, nerve lesions are often not detected in time, so that surgical treatment can only be initiated after a delay. Because of the relatively high proportion of iatrogenic nerve lesions, a profound knowledge of the optimal care of patients with peripheral nerve lesions is compulsory for every doctor who works in the operative field. Surgical treatment of peripheral nerve lesions should remain in the hands of experienced peripheral nerve surgeons. The foundation of successful treatment, however, begins earlier at the initial referral when the patient receives the correct diagnostics and treatment.

[Nerve injuries and traumatic lesions of the brachial plexus : Imaging diagnostics and therapeutic options]. / Nervenverletzungen und traumatische Läsionen des Plexus brachialis : Bildgebende Diagnostik und therapeutische Optionen.

CLINICAL/METHODICAL ISSUE: Traumatic lesions of peripheral nerves and the brachial plexus are feared complications because they frequently result in severe functional impairment. The prognosis is greatly dependent on the correct early diagnosis and the right choice of treatment regimen. It is important to distinguish between open and closed injuries. STANDARD RADIOLOGICAL METHODS: Initial imaging must critically evaluate or prove nerve continuity and is commonly achieved by high-resolution ultrasonography. During the further course, reactive soft tissue alterations, such as constrictive scarring or neuroma formation can be detected. In the case of deep nerve and plexus injuries this can be excellently achieved by dedicated magnetic resonance neurography (MRN) sequences. METHODICAL INNOVATIONS: The signal yield from brachial plexus imaging can be critically enhanced by the use of dedicated surface coil arrays. Furthermore, diffusion tensor imaging (DTI) may enable the regeneration potential of a nerve lesion to be recognized in the future. PERFORMANCE: Multiple reports have shown that neurosonography enables a precise evaluation of peripheral nerve structures (up to 90% sensitivity and 95% specificity in nerve transection) and that the method can critically impact on therapeutic decision-making in 60%. Currently, there are only few quantitative data on the exact performance of MRN in traumatic nerve lesions; however, individual reports indicate a high level of agreement with intraoperative findings. PRACTICAL RECOMMENDATIONS: In the initial work-up, especially in the case of peripheral, superficial and lesser nerve injuries, neurosonography is the preferred imaging approach to evaluate nerve integrity and the extent of nerve lesions. In the case of extensive nerve injury of proximal nerves and structures of the plexus as well as in the case of suspected root avulsion MRN is the method of choice.

Iatrogenic lesions of peripheral nerves.

Iatrogenic nerve lesions (INLs) are an integral part of peripheral neurology and require dedicated neurologists to manage them. INLs of peripheral nerves are most frequently caused by surgery, immobilization, injections, radiation, or drugs. Early recognition and diagnosis is important not to delay appropriate therapeutic measures and to improve the outcome. Treatment can be causative or symptomatic, conservative, or surgical. Rehabilitative measures play a key role in the conservative treatment, but the point at which an INL requires surgical intervention should not be missed or delayed. This is why INLs require close multiprofessional monitoring and continuous re-evaluation of the therapeutic effect. With increasing number of surgical interventions and increasing number of drugs applied, it is quite likely that the prevalence of INLs will further increase. To provide an optimal management, more studies about the frequency of the various INLs and studies evaluating therapies need to be conducted. Management of INLs can be particularly improved if those confronted with INLs get state-of-the-art education and advanced training about INLs. Management and outcome of INLs can be further improved if the multiprofessional interplay is optimized and adapted to the needs of the patient, the healthcare system, and those responsible for sustaining medical infrastructure.

Cubital tunnel syndrome - a review and management guidelines.

Cubital tunnel syndrome (CuTS) is the second most common peripheral nerve compression syndrome. In German-speaking countries, cubital tunnel syndrome is often referred to as sulcus ulnaris syndrome (retrocondylar groove syndrome). This term is anatomically incorrect, since the site of compression comprises not only the retrocondylar groove but the cubital tunnel, which consists of 3 parts: the retrocondylar groove, partially covered by the cubital tunnel retinaculum (lig. arcuatum or Osborne ligament), the humeroulnar arcade, and the deep flexor/pronator aponeurosis. According to Sunderland , cubital tunnel syndrome can be differentiated into a primary form (including anterior subluxation of the ulnar nerve and compression secondary to the presence of an anconeus epitrochlearis muscle) and a secondary form caused by deformation or other processes of the elbow joint. The clinical diagnosis is usually confirmed by nerve conduction studies. Recently, the use of ultrasound and MRI have become useful diagnostic tools by showing morphological changes in the nerve within the cubital tunnel. A differential diagnosis is essential in atypical cases, and should include such conditions as C8 radiculopathy, Pancoast tumor, and pressure palsy. Conservative treatment (avoiding exposure to external noxes and applying of night splints) may be considered in the early stages of cubital tunnel syndrome. When nonoperative treatment fails, or in patients who present with more advanced clinical findings, such as motor weakness, muscle atrophy, or fixed sensory changes, surgical treatment should be recommended. According to actual randomized controlled studies, the treatment of choice in primary cubital tunnel syndrome is simple in situ decompression, which has to be extended at least 5-6 cm distal to the medial epicondyle and can be performed by an open or endoscopic technique, both under local anesthesia. Simple decompression is also the therapy of choice in uncomplicated ulnar luxation and in most post-traumatic cases and other secondary forms. When the luxation is painful, or when the ulnar nerve actually "snaps" back and forth over the medial epicondyle of the humerus, subcutaneous anterior transposition may be performed. In cases of severe bone or tissue changes of the elbow (especially with cubitus valgus), the anterior transposition of the ulnar nerve may again be indicated. In cases of scarring, submuscular transposition may be preferred as it provides a healthy vascular bed for the nerve as well as soft tissue protection. Risks resulting from transposition include compromise in blood flow to the nerve as well as kinking of the nerve caused by insufficient proximal or distal mobilization. In these cases, revision surgery is necessary. Epicondylectomy is not common, at least in Germany. Recurrence of compression on the ulnar nerve at the elbow may occur. This review is based on the German Guideline "Diagnose und Therapie des Kubitaltunnelsyndroms" ( www.leitlinien.net ).

Surgical treatment of thoracic disc herniations via tailored posterior approaches.

We present clinical findings, radiological characteristics and surgical modalities of various posterior approaches to thoracic disc herniations and report the clinical results in 27 consecutive patients. Within an 8-year period 27 consecutive patients (17 female, 10 male) aged 30-83 years (mean 53 years.) were surgically treated for 28 symptomatic herniated thoracic discs in our department. Six of these lesions (21%) were calcified. In all cases surgery was performed via individually tailored posterior approaches. We evaluated the pre- and postoperative clinical status and the complication rate in a retrospective study. Nearly one half of the lesions (46.4%) were located at the three lowest thoracic segments. Clinical symptoms included back pain or radicular pain (77.8%), altered sensitivity (77.8%), weakness (40.7%), impaired gait (51.9%) or bladder dysfunction (22%). Costotransversectomy was performed in 8 patients, 1 lateral extracavitary approach, 2 foraminotomies, 15 transfacet and/or transpedicular approaches and 2 interlaminar approaches were used for removing the pathologies. After a mean follow-up of 38.6 months (3-100 months), complete normalization or reduction of local pain was recorded in 87% of the patients and of radicular pain in 70% of the cases, increased motor strength could be achieved in 55%, sensitivity improved in 76.2% and improvement of myelopathy was noted in 71.4%. Two patients suffered from postoperative impairment of sensory deficits, which in one case was discrete. The overall recovery rate within the modified JOA score was 39.5%. In 1 patient, two revisions were required because of instability and a persisting osteophyte, respectively. The rate of major complications was 7.1% (2/28). Surgical treatment of thoracic disc herniations via posterior approaches tailored to the individual patient produces satisfying results referring to clinical outcome. Posterior approaches remain a viable alternative for a large proportion of patients with symptomatic thoracic disc herniations.

Lows and highs: 15 years of development in intraoperative magnetic resonance imaging.

Intraoperative magnetic resonance imaging (ioMRI) during neurosurgical procedures was first implemented in 1995. In the following decade ioMRI and image guided surgery has evolved from an experimental stage into a safe and routinely clinically applied technique. The development of ioMRI has led to a variety of differently designed systems which can be basically classified in one- or two-room concepts and low- and high-field installations. Nowadays ioMRI allows neurosurgeons not only to increase the extent of tumor resection and to preserve eloquent areas or white matter tracts but it also provides physiological and biological data of the brain and tumor tissue. This article tries to give a comprehensive review of the milestones in the development of ioMRI and neuronavigation over the last 15 years and describes the personal experience in intraoperative low and high-field MRI.

Image guided aneurysm surgery in a Brainsuite® ioMRI Miyabi 1.5 T environment.

OBJECTIVE: Current literature only gives sparse account of aneurysm surgery in an intraoperative MRI environment. After installation of a BrainSuite(®) ioMRI Miyabi 1.5 T at our institution the aim of the present preliminary study was to evaluate feasibility, pros and cons of aneurysm surgery in this special setting. MATERIAL AND METHODS: Since February 2009, during a 3 months period we performed elective image guided aneurysm surgery in 4 ACM and 1 ACOM aneurysm (four patients) in this ioMRI setting. The patients' heads were rigidly fixed in the Noras 8-Channel OR Head Coil. Our imaging protocol included MP-RAGE, T2-TSE axial, TOF-MRA and diffusion-/perfusion-imaging immediately before surgery and after clip application. Presurgical 3D-planning was performed using the iPlan®-Software. RESULTS: All five aneurysms were operated without temporary clipping. There were no intra- or postoperative complications. Patient positioning and head fixation with the integrated Noras Head Clamp was feasible, but there were significant limitations particularly with regard to more complex approaches and patient physiognomy. Image quality especially TOF-MRA was good in 4, insufficient in 1 aneurysm. Presurgical planning especially vessel extraction from TOF-MRA was possible but certainly needs significant future improvement. Diffusion- and perfusion weighted examinations yielded good image quality. CONCLUSION: Our limited experience is encouraging so far. Further improvement particularly concerning flexibility of patient positioning and presurgical 3D-planning for vascular procedures is most necessary. As a future perspective image guided aneurysm surgery in an ioMRI-environment may be helpful especially in complex aneurysms and provide neurosurgeons and neuroanaesthesiologists with additional information about cerebral haemodynamics and perfusion pattern in the vascular territory distal to the target vessel.

The pyridinylfuranopyrimidine inhibitor, PI-103, chemosensitizes glioblastoma cells for apoptosis by inhibiting DNA repair.

The failure of conventional therapies in glioblastoma (GBM) is largely due to an aberrant activity of survival cascades, such as PI3 kinase (PI3K)/Akt-mediated signaling. This study is the first to show that the class I PI3K inhibitor, PI-103, enhances chemotherapy-induced cell death of GBM cells. Concurrent treatment with PI-103 and DNA-damaging drugs, in particular doxorubicin, significantly increases apoptosis and reduces colony formation compared with chemotherapy treatment alone. The underlying molecular mechanism for this chemosensitization was shown by two independent approaches, that is, pharmacological and genetic inhibition of PI3K, DNA-PK and mTOR, to involve inhibition of DNA-PK-mediated DNA repair. Accordingly, blockage of PI3K or DNA-PK, but not of mTOR, significantly delays the resolution of doxorubicin-induced DNA damage and concomitantly increases apoptosis. Importantly, not only are several GBM cell lines chemosensitized by PI-103 but also GBM stem cells. Clinical relevance was further confirmed by the use of primary cultured GBM cells, which also exhibit increased cell death and reduced colony formation on combined treatment with PI-103 and doxorubicin. By identifying class I PI3K inhibitors as powerful agents in enhancing the lethality of DNA-damaging drugs, to which GBMs are usually considered unresponsive, our findings have important implications for the design of rational combination regimens in overcoming the frequent chemoresistance of GBM.

[Diagnosis and therapy of cubital tunnel syndrome--state of the art]. / Aktueller Stand der Diagnostik und Therapie des Kubitaltunnelsyndroms.

The cubital tunnel syndrome is one of the most widespread compression syndromes of a peripheral nerve. In German-speaking countries it is known as the sulcus ulnaris syndrome (retrocondylar groove syndrome), which is anatomically incorrect. The cubital tunnel consists of the retrocondylar groove, the cubital tunnel retinaculum (Lig. arcuatum or Osborne band), the humeroulnar arcade and the deep flexor/pronator aponeurosis. According to Sunderland it can be divided into a primary form (including the ulnar luxation and the epitrocheoanconaeus muscle) and a secondary form caused by deformation or other processes of the elbow joint. The diagnosis has to be confirmed by a thorough clinical examination and nerve conduction studies. Neurosonography and MRI are becoming more and more important with improving resolution and enable the direct identification of morphological changes. Differential diagnosis is essential in atypical cases, especially C8 syndrome and pressure palsy. Double crush (double compression syndrome) may occur. Operative treatment is more effective than conservative treatment, which consists primarily of the prevention of exposure to external noxes. According to actual randomised controlled studies the therapy of choice of the primary form in most cases is the simple in situ decompression of the ulnar nerve in the cubital tunnel. This has to be extended at least up to 5-6 cm distally of the medial epicondyle and can be performed in the open or endoscopic technique, both under local anesthesia. Simple decompression is also the therapy of choice in uncomplicated ulnar luxation and in most post-traumatic cases and other secondary forms. In cases of severe bony or tissue changes of the elbow (especially cubitus valgus) the volar transposition of the ulnar nerve may be indicated. This can be performed in a subcutaneous or submuscular technique. Risks of transposition are impairment of perfusion and, above all, kinking caused by insufficient proximal or distal mobilisation of the nerve has to be avoided. In these cases revision surgery is necessary. The epicondylectomy is not common in our country. Recurrences may occur.

[The endoscopic management of the cubital tunnel syndrome--an anatomical study and first clinical results]. / Die endoskopische Dekompression des Kubitaltunnelsyndroms--Anatomische Grundlagen und erste klinische Ergebnisse.

Besides the carpal tunnel syndrome, the cubital tunnel syndrome (CuTS) represents the second most frequent nerve entrapment syndrome. The current gold standard for surgical therapy consists of simple open decompression. Recently, an endoscopic procedure involving long-distance decompression of the ulnar nerve has been developed and this is the topic of the present study. The first part of this paper describes preliminary anatomic investigations on 22 cadaver arms. In every sample we observed a thickening of the submuscular membrane between the heads of the flexor carpi ulnaris (FCU) which surrounds the ulnar nerve. This was especially the case for the first 10 cm from the medial epicondyle In the second part we report our experiences with this endoscopic decompression procedure in 36 patients. With this endoscopic decompression we achieved good to very good results according to the Bishop classification in 28 patients (78%). On the basis of anatomic considerations and our current experience, the endoscopic procedure seems to represent a promising alternative to simple decompression.

Foramen magnum meningiomas--experience with the posterior suboccipital approach.

The aim of this study is to analyse short- and long-term results after surgical treatment of foramen magnum meningiomas and to identify the possible advantages of the posterior suboccipital approach over lateral and anterior approaches. Between 1992 and 2006, 16 patients with foramen magnum meningiomas were operated on in our institution, and in all cases a posterior suboccipital approach was utilised with lateral extension of the bone opening according to the position of the tumour. In 14 patients, intraoperative monitoring of the lower cranial nerves was performed. Localisation of the tumours was ventral (3), ventrolateral (10), dorsal (1) and dorsolateral (2). Mean age of the patients was 61 years (ranging from 40 to 85 years). Preoperative and postoperative function was classified according to the McCormick scale. We found in eight patients a postoperative upgrading of at least one grade, in five patients an unchanged status and a deterioration in only two patients. Complete removal of the tumour was possible in 14 cases (Simpson 1-2). The follow-up period varied from 24 to 119 months (mean 43.5 months), during this time there were no recurrences. Removal of foramen magnum meningiomas can be performed safely today with the use of microsurgical techniques and intraoperative monitoring. In our experience, the posterior suboccipital approach is suitable for the majority of these tumours.

Intraneural perineuriomas; a rare entity. Clinical, surgical and neuropathological details in the management of these lesions.

OBJECTIVE: Perineuriomas are rare benign peripheral nerve sheath tumors, which have only been included in the WHO classification system since 2000. They are divided into intraneural perineuriomas and soft tissue tumors. Intraneural perineuriomas were previously known as localized hypertrophic neuropathies. Because of their rarity there are only case reports in the literature. METHODS: Between 1992 and 2006 surgery was performed on four patients suffering from intraneural perineuriomas in our hospital. All patients were males, aged five, ten, twenty and twenty-nine years old. One of the tumors occurred in the ulnar nerve, one in the common peroneal part of the sciatic nerve and two of them in the radial nerve. In a retrospective study the clinical, electrophysiological and imaging data of the patients was analyzed. Two of these patients had previously been treated with decompression and neurolysis of the nerve for the suspicion of a nerve compression syndrome. Revisions were necessary following progressive neurological deterioration postoperatively. Explorations of the nerves showed nerve tumors. The tumors were resected and nerve grafting was performed. CONCLUSIONS: These tumors tend to affect the nerves of the upper extremities in children or young adults. The predominant symptom is a slow-progressive paralysis. Two of the four patients showed a partial improvement of their motor and sensorial nerve deficits in the long-term follow-up following complete tumor resection and interpositional autologous nerve grafts. No relapse could be observed. In cases of slow-progressive neurological deficits of a peripheral nerve in young patients the differential diagnosis should include the intraneural perineuriomas.

[Diagnosis and therapy of carpal tunnel syndrome--guideline of the German Societies of Handsurgery, Neurosurgery, Neurology, Orthopaedics, Clinical Neurophysiology and Functional Imaging, Plastic, Reconstructive and Aesthetic Surgery, and Surgery for Traumatology]. / Diagnostik und Therapie des Karpaltunnelsyndroms--Leitlinie der Deutschen Gesellschaften für Handchirurgie, Neurochirurgie, Neurologie, Orthopädie unter Mitbeteiligung der Gesellschaften für Unfallchirurgie, Klinische Neurophysiologie und Funktionelle Bildgebung sowie Plastiche, Rekonstruktive und Asthetische Chirurgie.

Evidence-based supradisciplinary guideline that deals with the epidemiology, pathogenesis, symptoms, clinical and electrophysiological diagnosis, supplementary imaging investigations, differential diagnosis, conservative and surgical treatments, prognosis and course along with complications and revision surgery. The recommendations on investigation and treatment are based on a comprehensive literature search with critical evaluation and two consensus methods (expert group and Delphi technique) within the participating specialist societies. Besides this long version, a short version and a patient version can be viewed through the AWMF platform. The development of the guideline and the methodological foundations are documented in a method report. MAIN STATEMENTS: Apart from an accurate history and clinical neurological examination (including clinical tests), electrophysiological investigations (distal motor latency and sensory neurography) are particularly important. Radiography, MRI, high-resolution ultrasonography can be regarded as optional supplementary investigations. Among conservative treatment methods, treatment with a nocturnal splint and local infiltration of a corticosteroid preparation are effective. Oral steroids, splinting and ultrasound showed only short-term benefit. Surgical treatment is clearly superior to all other methods. Open and endoscopic procedures (when the endoscopic surgeon has sufficient experience) are equivalent. A routine epineurotomy and interfascicular neurolysis cannot be recommended. Early functional treatment postoperatively is important.

Neurosurgical management of previously coiled recurrent intracranial aneurysms.

OBJECTIVE: Endovascular treatment of cerebral aneurysms with detachable coils has proven to be a save and effective treatment. But long-term recurrence due to aneurysm regrowth or coil compaction has been reported in up to thirty percent of cases. Therefore a growing number of previously coiled aneurysms have to be retreated by coiling or, in some circumstances, by clipping. We present a consecutive series of ten patients who underwent surgical clipping for recurrent aneurysms after primary coil embolization. METHODS: During a 4-year period ten patients with intracranial aneurysms previously treated by coil embolization underwent surgery for clipping of recanalized aneurysms. All aneurysms were located in the anterior circulation (internal carotid artery [ICA], 2; middle cerebral artery [MCA], 3; anterior communicating artery [AcomA], 5). Clinical data and imaging studies of the patients were analyzed retrospectively. RESULTS: All recurrences were detected by routine control angiograms within a median period of 14 months after primary treatment. In three aneurysms treated for SAH dense arachnoid scarring around the aneurysm sac was noted. In four cases, coils were found intraoperatively to be extruding through the aneurysm sac into the subarachnoid space. Each aneurysm could be clipped without affecting the perfusion of the parent vessel. In one patient the aneurysm sac including the coil package was resected. In one patient one of the central anteromedial arteries was injured during dissection due to dense arachnoid scarring because of prior SAH. As a consequence infarction of the head of the caudate nucleus without neurological compromise was observed on follow-up CT scans. Another patient developed transient aphasia due to vasospasm in the early postoperative period with complete restitution. In the end all patients had an uneventful recovery. Removal of the coil package was not necessary in most cases. Clipping of the aneurysm neck was possible even in cases with coil dislocation into the parent vessel. CONCLUSION: Clipping of previously coiled aneurysms is a unique problem for vascular neurosurgeons. In most cases clipping is feasible. Clipping should still be considered as a definite treatment option in previously coiled recurrent aneurysms. Results in this small series were good.

[Subcranial resection of malignant tumors infiltrating the anterior skull base]. / Subkranialer Zugang bei Malignomen mit Beteiligung der Frontobasis.

BACKGROUND: Survival and quality of life after subcranial resection of malignant tumors infiltrating the anterior skull base should be evaluated. METHODS: Data were acquired retrospectively from patient charts and by telephone interview. Quality of life was assessed with the EORTC QLQ30 and H&N35 modules. RESULTS: From 1996 to 2004, 19 patients (mean age 52 years, 4 woman, 15 men) were surgically treated via a subcranial approach. Fifteen patients suffered from advanced carcinoma, 3 from advanced esthesioneuroblastoma, and 1 patient had a fibrosarcoma. Fifteen patients received adjuvant radiotherapy. During the mean follow-up period of 44 months (12-109 months), 6 patients died, 1 unrelated to the tumor. The probability to survive 5 years was 50 %, the mean survival time was 72 months. Anosmia was reported by 18 of 19 patients. A tension pneumocephalus was observed in 2 patients, one with lethal outcome, decreased vision in 1 patient, loss of vision in 1, persisting diplopia in 1, deep wound infections in 2, and CSF leak in 2 patients. Quality of life was assessed on the average 36 months following end of therapy and did not differ substantially from other patients with head-neck malignancies. CONCLUSION: Most, malignant tumors infiltrating the anterior skull base can be treated curatively. The treatment outcome is well comparable to other head and neck tumors of corresponding stage.

[Is surgery likely to be successful as a treatment for traumatic lesions of the superficial radial nerve?]. / Ist ein chirurgisches Vorgehen bei traumatischen Läsionen des Ramus superficialis N. radialis Erfolg versprechend?

In the last 10 years 22 patients with lesions of the superficial branch of the radial nerve have been treated surgically in our neurosurgical department. The patients' main complaints were burning pain and paraesthesia in the region supplied by the superficial branch of the radial nerve. In most cases the lesion was due to tendolysis performed earlier to treat de Quervain tendovaginitis stenosans. In 8 cases external neurolysis was done with conservation of continuity; in 4 cases the nerve was reconstructed after resection of the neuroma (end-to-end-suture or implantation of a vicryl conduit); and in 10 cases the neuroma was resected and transposition of the proximal nerve end was performed. Nineteen patients were available for evaluation of the postoperative results, after an average follow-up of 51 months. Surprisingly, only 5 reported good subjective improvement of pain after surgery. Seven patients reported an unchanged status postoperatively, and in 1 case the pain was even worse after the surgical intervention. Satisfactory results (complete or partial pain relief in 75% of cases) was found to have been achieved in the subgroup of patients treated by resection of the neuroma of the superficial branch of the radial nerve and transposition of the nerve stump. In conclusion, we recommend caution when surgical interventions are considered for traumatic lesions of the superficial radial nerve, because the prospects of success are limited. In addition, we do not consider nerve reconstruction desirable in these circumstances.

[Neurogenic thoracic outlet syndrome. Long-term results of supraclavicular decompression]. / Neurogenes Thoracic-outlet-Syndrom. Langzeitergebnisse der supraklavikulären Dekompression.

OBJECTIVES: Neurogenic thoracic outlet syndrome (TOS) is one of the most controversial entrapment syndromes of the upper extremity. There are two different surgical approaches for its primary surgical treatment: supraclavicular decompression and transaxillary first rib resection. The aim of this study was to evaluate long-term results and surgical risks of the former. METHODS: This retrospective long-term study examines a series of 50 supraclavicular decompressions in 45 patients. Follow-up was for at least 24 months. All patients were reexamined regularly in nonstandardized fashion. Finally, each patient underwent a telephone interview with a standardized questionnaire. RESULTS: There was a significant deterioration of primary results during follow-up. About 30.0% of cases worsened within 24 months after operation. In the long run, about 80.0% of cases showed improvement of symptoms (26.0% excellent, 36.0% good, 18.0% moderate). The complication rate was 4.0%. CONCLUSION: Due to secondary deterioration of treatment during follow-up, only long-term studies are suited for the examination of neurogenic TOS. Results after supraclavicular decompression are satisfactory, and the complication rate is low.

[Spinal intramedullary tumors. When is surgical treatment indicated?]. / Spinale intramedulläre Tumoren Wann ist die operative Behandlung angezeigt?

OBJECTIVE: Timing of surgery in patients with intramedullary tumors is the subject of controversy. The aim of this retrospective study is to evaluate whether patients with intramedullary ependymomas and astrocytomas have a better postoperative prognosis without or with slight preoperative deficits than those with severe preoperative neurological disturbances. PATIENTS AND METHODS: During a period of 8.5 years (January 1992-August 2000), 34 patients with intramedullary tumors underwent surgery in our Neurosurgical Department. Among them there were five astrocytomas WHO grade II and ten ependymomas WHO grade II. Recurrences were observed in two patients with astrocytomas and one patient with ependymoma. Pre- and postoperative functional performance was classified according to the McCormick scale in grade I-IV (grade I: neurologically normal or mild focal deficit and grade IV: severe neurological deficits and without functional independence). The follow-up period varied from 4 to 76 months (mean: 27.9 months). RESULTS: All seven grade I patients remained unchanged after surgery. Two of four grade II patients improved to grade I; two deteriorated to grade III. Two of three grade III and IV patients remained unchanged and another one deteriorated from grade III to IV. CONCLUSION: At the best, intramedullary astrocytomas and ependymomas should be operated when symptoms are mild. Early surgery can achieve good functional outcome.