Combined craniofacial approach to facial tumours involving the anterior skull base.

The authors report their experience on six male patients and one female patient (age range: 58-76 years, median: 67) with facial tumours involving the anterior skull base, undergoing craniofacial resection between January 1992 and May 1994 at the Division of Surgical Oncology in the Tumor Institute, Genoa. Three patients had squamous carcinoma and adenocarcinoma of the nasal fossa; two patients had squamous carcinoma rT4NO and adenocarcinoma rT4NO1 of the maxillary sinus; one patient had squamous carcinoma of the eyelid, and another had squamous carcinoma of the internal chantus. Four patients had had previous radiotherapy, another underwent pre-operative chemoradiotherapy, and only two patients had not been treated before. A proper craniofacial tumour resection was performed in three patients; one patient had a left maxillectomy with ethmoidectomy and orbital exenteration; one patient underwent maxillectomy, resection of the medial and inferior wall of the orbit, ethmoidectomy, and orbital exenteration; one patient underwent maxillectomy, ethmoidectomy, and mucosectomy of the sphenoidal sinus, and one patient had total ethmoidectomy. As for reconstruction procedures of the anterior skull base, lyophilized dura with galeal pericranial flap was commonly used. A myocutaneous flap transposition (transverse rectus abdominis and latissimus dorsi myocutaneous flap) was used in two patients for the reconstruction of the resected tissues and bones of maxillary and orbital regions. Post-operative complications included intraoperative liquorrhea in one patient; one case of early and serious pneumocephalus; flap necrosis occurred following transposition of latissimus dorsi. Median hospital stay was 34 days. After a median follow-up of 18 months (range: 3 to 34 months) five of seven patients (71.4%) are alive and disease-free at 15, 17, 18, 30 and 34 months from surgery.

Surgical treatment of fractures of the thoracic and lumbar spine via the transpedicular route.

Sixty-seven consecutive patients with burst or dislocation fractures of the thoracic or lumbar spine were submitted to early surgical reduction, via the transpedicular route, over a 5-year period. The first 22 patients received Harrington instrumentation, while transpedicular devices were applied in the last 44 cases, at either the thoracic or the lumbar level. One patient did not receive any spinal instrumentation. This surgical approach was found to be reliable in achieving a near-anatomical reconstruction of the fractured spinal segment. The rate of post-operative complications was low. Placement of transpedicular devices proved to be a safe and effective procedure. The overall results were consistent with the thesis that the transpedicular approach compares favourably with alternative surgical methods.

Delayed worsening of the surgical correction of angular and axial deformity consequent to burst fractures of the thoracolumbar or lumbar spine.

Forty-one patients with burst fractures of the thoracolumbar junction, or the lumbar spine (T12 to L5), were followed for 6-48 months (mean follow-up = 19.9 months) after early surgery (usually within 24 hours). Preoperative, early postoperative, and late postoperative degrees of kyphosis, as well as percent reduction of the height of the vertebral body were calculated and compared. Early postoperative radiologic evaluations showed a statistically significant difference (p < 0.0001) between the mean values of both parameters calculated respectively before and after surgery. The decrease of the surgical correction, from the initial postoperative radiographs to follow-up, was statistically significant (p < 0.0001). However, the final values were better when compared with the preoperative features (p < 0.003 and p < 0.0001, respectively for degree of kyphosis and reduction in vertebral height.

Spinal cord stimulation for the treatment of progressive systemic sclerosis and Raynaud's syndrome.

Progressive Systemic Scleroderma (PSS) is a generalized disease of connective tissue involving the skin, as well as other internal organs. The cutaneous signs are characterized by a progressive sclerosis and loss of function or dexterity in the hands. Between 1987 and 1992, 15 patients affected by scleroderma were treated by means of spinal cord stimulation (SCS) in order to reduce signs and symptoms related to vascular damage. The follow-up ranged from 12 months to 6 years. The study confirms that SCS is an effective therapy in patients with PSS and Raynaud's phenomenon because of its beneficial effects on the Raynaud episodes, ulcers, pain, vascular sclerosis and hand function. This method may have a primary role in the treatment of this chronic disorder because of the high probability of failure of other medical or surgical therapy.

Transpedicular decompression and stabilization of burst fractures of the lumbar spine.

Twenty-seven consecutive patients with neurological impairment due to burst fractures of the lumbar spine were operated upon, via the postero-lateral route, over a 38-month-period. Transpedicular fixation devices [posterior segmental fixator (PSF) or variable screw placement system (VSP)] were applied in all cases, in order to achieve short-segment fusion of the fractured spinal segment. Return to useful motor power or neurological normality (median follow-up: 18.7 months) occurred in 22 cases (81% of the whole series), with this outcome resulting in all but one of the cases with preoperative incomplete neurological deficit. Postoperative encroachment of the spinal canal, degree of kyphotic deformity, and reduction of the vertebral height showed statistically significant differences compared with the corresponding preoperative values.

Near-anatomical reduction and stabilization of burst fractures of the lower thoracic or lumbar spine.

Thirty-one consecutive symptomatic patients with burst fractures of the lower thoracic or lumbar spine (T 11-L4) were treated by early surgery in a 36-month period, with near-anatomical reduction being achieved via the postero-lateral route. Fusion and reconstruction of the vertebral body was done by using autologous or processed bovine bone. Correction of the kyphotic deformity was obtained by using distraction rods or transpedicular devices. The post-operative mean degree of kyphosis, percent vertebral height, and percent canal stenosis showed statistically significant differences, compared with the corresponding pre-operative mean values. All but one of the 25 patients with incomplete paraplegia exhibited neurological improvement, with complete recovery occurring in 20 cases (median follow-up: 16 months) irrespective of the location of the lesion at the thoraco-lumbar junction (T 11-L1) or the lower lumbar segment (L2-L4). Out of the 6 patients with pre-operative complete paraplegia, useful motor power returned in one case with a lesion below L1. The results confirm the suitability of the postero-lateral route and are consistent with the assumption that early near-anatomical reduction and stabilization favours maximum neurological recovery in symptomatic patients.

Spinal subarachnoid hematoma of unknown etiology. A case report.

A case of spinal subarachnoid hematoma at T3-T7 level is reported in a 60-year-old hunter, who developed progressive spinal cord impairment after receiving the recoil of his shotgun. Both clinical and neuroradiological investigations, including the selective spinal angiography, failed to demonstrate the origin of the bleeding. The combination of an apparently trivial spinal trauma with temporary increase of the intrathoracic pressure might be considered as possible etiologic factor.

On the predictive value of radiological signs for the presence of dural lacerations related to fractures of the lower thoracic or lumbar spine.

The predictive value of radiological signs for the presence of lacerations of the thoracolumbar dura in spine-injured patients could represent an important adjunct to the rationale for the optimal management, owing to the possible onset of early or delayed complications of these lesions. Occurrence of signs assumed to be related to dural tears, such as separation of the pedicles, fractures of the laminae, and encroachment of the spinal canal, was analyzed in a consecutive series of 25 patients submitted to surgical reduction and stabilization of the fractured lower thoracic or lumbar spine in a 24-month period. No statistically significant correlation was found between dural lacerations and any of the examined signs. Leaks of cerebrospinal fluid through traumatic breachs of the meninges were found in 16 of the 25 cases. The high rate of occurrence of dural lesions associated with fractures of the lower thoracic or lumbar spine adds a further argument to the aggressive approach to these injuries.

Metoclopramide increases plasma but not cerebrospinal fluid vasopressin levels in man: study in hydrocephalic patients.

Arginine vasopressin (AVP) concentrations were determined in plasma and in cerebrospinal fluid (CSF) in 8 adult male patients suffering from hydrocephalus of various etiologies, before and after intravenous administration of 10 mg metoclopramide. Metoclopramide was able to increase the plasma (2.6 +/- 0.2 ng/l in basal conditions and 6.1 +/- 0.6 ng/l at 30 min) but not the CSF AVP levels. The results suggest that the neurons which secrete AVP into the CSF may be functionally different from those secreting into the peripheral circulation.

[Possible role of 06-methylguanine-DNA-transferase in the response of patients with primary tumor of the brain to chemotherapy using chloro-ethyl-nitroso-urea: results of a current study]. / Possible ruolo della 06-metilguanina-DNA-Transferasi nella risposta di pazienti con tumori cerebrali primitivi alla chemioterapia con Cloro-Etil-Nitroso-Uree: risultati di uno studio in corso.

We have started a study to measure the MT activity in surgical specimens from high grade human malignant gliomas, with the dual aim to (i), know whether lack of activity can be demonstrated in these tumors, and (ii), relate the measured levels of MT to the histology of the tumors and to the response of patients to chemotherapy with 1-(2-Chloroethyl)-3-Cyclohexyl-1-Nitrosourea (CCNU). To date, 12 Gliomas have been assayed. In 11 tumors, MT activities ranging from 30 to 150 fmoles/mg protein have been measured. The only negative specimen derived from a patient who had received radiotherapy before surgery. At the present stage of the study, therefore, we have no unequivocal evidence for the existence of MT-deficient Gliomas.

Subarachnoid buprenorphine administered by implantable micropumps.

This report concerns 23 patients, the majority of whom are suffering from low back and chest pain caused by chest, urological or gynaecological cancer. These patients were treated with subarachnoid buprenorphine, administered in a single bolus or by slow infusion from micropumps, at a daily dose adapted to patients need (0.06-0.15 mg). The painful symptomatology was successfully controlled in all the cases treated, allowing the patients to live a virtually normal life. In no cases was respiratory depression or tolerance observed.

Photodynamic therapy of malignant brain tumors: clinical results of, difficulties with, questions about, and future prospects for the neurosurgical applications.

Photodynamic therapy (PDT) has been applied in a variety of oncological fields with good results. In neurosurgery, the clinical series are limited and the number of treated patients is not statistically significant. This work examines the results of PDT performed in our clinic and discusses some difficulties and causes of failure of this method in neurosurgical patients. Eight patients with malignant brain tumors underwent PDT. All had been treated previously by operation and radiation therapy and one patient had also received chemotherapy. At 24 hours after the i.v. injection of hematoporphyrin (5 mg/kg body weight), the tumor was removed as radically as possible and the residual tumor bed was exposed to either 630-nm light from an argon-dye laser or 600- to 680-nm light isolated from the emission of a quartz-halogen lamp. The type of sensitizer, the irradiation methods, and the peculiarities of glial tumors are examined as possible causes of failure. The longer survivals of some patients with glial tumors treated by PDT may make this treatment suitable when traditional therapies fail.

Diurnal pattern of plasma and cerebrospinal-fluid vasopressin levels in hydrocephalic patients: absence of a circadian rhythm and of a correlation between plasma and cerebrospinal-fluid variations.

The arginine vasopressin (AVP) concentrations were determined in plasma and in cerebrospinal fluid (CSF) during a 24-hour period in 7 male patients suffering from hydrocephalus of differing etiologies. Blood and ventricular CSF samples were simultaneously collected every 2 h during the day (08.00-22.00) and every hour during the night (24.00-07.00). In both plasma and CSF, the AVP levels did not show significant time-related circadian variations. No significant correlation was found between the plasma and CSF AVP values during the 24-hour period. The data obtained indicate the absence of the plasma and CSF AVP circadian rhythm in hydrocephalic patients and suggest that in these patients, and possibly in healthy humans, physiological stimuli which are able to induce variations in the plasma AVP concentration during daily life do not alter the CSF AVP content.

Diurnal changes of plasma and cerebrospinal fluid somatostatin and 24-h growth hormone secretory pattern in man. A study in hydrocephalic patients.

Somatostatin concentration was determined in plasma and in cerebrospinal fluid during a 24-h period in 7 male patients suffering from hydrocephalus of differing aetiologies. Blood and ventricular cerebrospinal fluid samples were taken every 2 h during the day (08.00-22.00 h) and every hour during the night (24.00-07.00 h). Simultaneously, plasma growth hormone levels were also evaluated. Plasma SRIH levels showed significant circadian variations with highest values in the daytime and lowest values during the night. Cerebrospinal fluid SRIH did not show any significant time-related circadian changes. Plasma GH levels showed the well-known circadian pattern in the majority of patients. No significant correlation was found between the plasma GH and plasma or cerebrospinal fluid SRIH values recorded during the 24-h period. Results suggest that peripheral SRIH does not play any major role in the control of the 24-h GH secretory pattern in man.

Diurnal beta-endorphin changes in human cerebrospinal fluid.

Plasma and cerebrospinal fluid (CSF) beta-endorphin levels were determined by a RIA method in seven hydrocephalic male patients. The samples were simultaneously collected every two hours from 8 AM to 12 midnight and every hour from 1 AM to 7 AM. In both plasma and CSF beta-endorphin levels showed significant time-related variations during the 24 hour period. These results suggest the existence of diurnal CSF beta-endorphin variations analogous to those observed in plasma.

Variations of prolactin content in human cerebrospinal fluid after metoclopramide and morphine.

Serum and cerebrospinal fluid (CSF) prolactin (PRL) concentrations were determined in fourteen patients of both sexes suffering from hydrocephalus, in basal conditions and after i.m. administration of 10 mg metoclopramide or 10 mg morphine. A significant increase in both serum and CSF hormone values was found after administration of both drugs. Serum and CSF PRL values after metoclopramide administration increased earlier and to a greater extent than after morphine. Furthermore, the metoclopramide induced CSF PRL increase immediately followed the serum peak, whereas after morphine administration an evident delay in the CSF hormone peak with respect to the serum increase was found. These data suggest that PRL entry in the CSF compartment is subject to a controlling mechanism which acts at the blood/brain barrier.

Diurnal prolactin changes in human cerebrospinal fluid.

Eight adult male patients suffering from hydrocephalus of differing aetiologies were investigated in order to detect the existence of diurnal variations of prolactin (PRL) concentration in human cerebrospinal fluid (CSF). Blood and ventricular CSF samples were taken every 2 h during the day (0800-2200 h) and every hour during the night (2300-0700 h). CSF mean PRL levels showed significant nyctohemeral variations with low levels (2.1 +/- 0.3 ng/ml) during day-time and higher levels at night (3.3 +/- 0.1 ng/ml), similar to that observed in serum (PRL values: 16.4 +/- 5.2 and 24.8 +/- 4.3 ng/ml during day and night periods respectively). The presence of a 24 h CSF PRL secretory profile similar to that in serum was shown in six patients with normal 24 h mean PRL values and normal diurnal changes in serum. In two patients with an altered serum 24 h secretory pattern no significant nyctohemeral variations in CSF PRL levels were found. Present data show the existence in man of nyctohemeral variations in CSF PRL content related to the 24 h changes of PRL levels in serum.

Evaluation of anterior pituitary function in adult patients with craniopharyngiomas.

Serum LH, FSH, TSH, PRL, GH and cortisol levels were measured in 10 patients with a craniopharyngioma both before and after a combined insulin-induced hypoglycaemia, GnRH and TRH test. In pre-operative studies, only two patients did not show hormonal abnormalities, while eight patients had deficiencies of one or more hormones. The most frequent abnormality was GH deficiency (six cases), followed by gonadotropin (four cases), cortisol (four cases), and TSH (one case), whereas four patients showed high serum PRL values. In post-surgical studies, a significant improvement of pituitary function was observed in two cases, whereas an impairment of previously normal corticotropin reserve was recorded in another case. The data obtained suggest that endocrine abnormalities in patients with craniopharyngiomas are irreversible in most cases.

Changes of CSF prolactin induced by metoclopramide in man.

A sharp increase in serum and CSF prolactin (PRL) values after acute metoclopramide (10 mg i.m.) administration was found in six male patients without endocrine diseases. Peak values occurred simultaneously in serum and in CSF. This finding suggests the possibility that CSF PRL content depends also on the retrograde transport from pituitary gland.