[Unusual course of a planned lumbar microdiscectomy]. / Ungewöhnlicher Verlauf einer elektiv geplanten lumbalen Bandscheibenoperation.

We report the case of a 30-year-old female patient who underwent unilateral transverse sinus stenosis stenting due to a newly diagnosed idiopathic intracranial hypertension (Pseudotumor cerebri) with symptoms of papilledema, decreased visual acuity and headache. Resolution of the symptoms and improvement of magnetic resonance and ophthalmiologic findings could be documented.

Complications of transpedicular screw fixation in the cervical spine.

Today, posterior stabilization of the cervical spine is most frequently performed by lateral mass screws or spinous process wiring. These techniques do not always provide sufficient stability, and anterior fusion procedures are added secondarily. Recently, transpedicular screw fixation of the cervical spine has been introduced to provide a one-stage stable posterior fixation. The aim of the present prospective study is to examine if cervical pedicle screw fixation can be done by low risk and to identify potential risk factors associated with this technique. All patients stabilized by cervical transpedicular screw fixation between 1999 and 2002 were included. Cervical disorders included multisegmental degenerative instability with cervical myelopathy in 16 patients, segmental instability caused by rheumatoid arthritis in three, trauma in five and instability caused by infection in two patients. In most cases additional decompression of the spinal cord and bone graft placement were performed. Pre-operative and post-operative CT-scans (2-mm cuts) and plain X-rays served to determine changes in alignment and the position of the screws. Clinical outcome was assessed in all cases. Ninety-four cervical pedicle screws were implanted in 26 patients, most frequently at the C3 (26 screws) and C4 levels (19 screws). Radiologically 66 screws (70%) were placed correctly (maximal breach 1 mm) whereas 20 screws (21%) were misplaced with reduction of mechanical strength, slight narrowing of the vertebral artery canal (<25%) or the lateral recess without compression of neural structures. However, these misplacements were asymptomatic in all cases. Another eight screws (9%) had a critical breach. Four of them showed a narrowing of the vertebral artery canal of more then 25%, in all cases without vascular problems. Three screws passed through the intervertebral foramen, causing temporary paresis in one case and a new sensory loss in another. In the latter patient revision surgery was performed. The screw was loosened and had to be corrected. The only statistically significant risk factor was the level of surgery: all critical breaches were seen from C3 to C5. Percutaneous application of the screws reduced the risk for misplacement, although this finding was not statistically significant. There was also a remarkable learning curve. Instrumentation with cervical transpedicular screws results in very stable fixation. However, with the use of new techniques like percutaneous screw application or computerized image guidance there remains a risk for damaging nerve roots or the vertebral artery. This technique should be reserved for highly selected patients with clear indications and to highly experienced spine surgeons.

[Results of simple fragment excision in lumbar disc surgery]. / Ergebnisse der alleinigen Sequestrektomie bei lumbaler Bandscheibenoperation.

BACKGROUND: While performing microsurgical disc excision, usually the sequestrated disc fragments as well as loosened or degenerated parts of the nucleus pulposus are removed. It is controversial whether this strategy is always necessary. The aim of this study was to examine this question based on clinical results. MATERIAL AND METHODS: Prospectively all relevant data from 149 consecutive patients after sequestrectomy were collected including the clinical course of the patients with a mean follow-up of 2.3 years. A detailed analysis of the actual pain status, the functional capacity and possible additional spinal operations was performed. RESULTS: During early follow-up, there was one superficial wound infection, which was treated conservatively. The success rate, as measured by patient self-assessment, was 62% for excellent and good and 25% for fair results; 13% of the patients treated declared a poor result having no benefits from surgery. The average FFbH score during follow-up was 74% (100% means no functional restriction). Radicular pain and low back pain had the same intensity on the average, in contrast to some other investigations, where low back pain was lower than radicular pain [14]. Of the 149 patients, 4 underwent a second spine surgery at the same level, 2 of which were recurrent disc herniations (=1.3%). CONCLUSION: Simple fragment excision revealed similar results compared to standard microdiscectomy. There was an especially low number of recurrences in contrast to former reports [16]. This was probably caused by the conscientious selection of patients for sequestrectomy according to well-defined criteria. Whether simple sequestrectomy can effectively treat an additional low back pain component must be clarified by further prospective studies.

Percutaneous transarticular atlantoaxial screw fixation using a cannulated screw system and image guidance.

In 2000 a cannulated screw stabilization system for posterior cervical instrumentation was introduced in our department for use in complex cervical fixation procedures. A special feature of the system is the use of thin Kirschner wires for drilling the screw paths and then placing the self-drilling, cannulated screws securely over the wires. Percutaneous application of C1-C2 transarticular screws is possible through tubes. An optional "atlas-claw" provides additional stability in cases of C1-C2 stabilization. 17 patients (10 female, 7 male, mean age 60 years) with complex cervical disorders and instability of different origin were stabilized using the Neon System (Ulrich Co., Ulm, Germany). Pathology included atlantoaxial instability based on rheumatoid arthritis (n = 12), odontoid fracture (n = 4) and os odontoideum mobile (n = 1). Computed navigation (STN 4.0, Zeiss or vector vision spine, brain lab) was used in 14 cases. Transarticular C1-C2 screw fixation was performed in 14 cases (4 patients with direct C1 massa lateralis screw fixation), craniocervical fixation (C0-C2/C3) was done in 3 patients. Percutaneous application of the C1-C2 screws was used in 7 patients. Atlas claws were applied in 8 patients. There was one medial perforation of a C2 pedicle wall and one malposition of the screw in C2 without reaching the lateral mass of C1. After a mean follow-up of 9 months there were no hardware failures and stable fusion in those cases followed after 12 months or more. Clinical results were excellent or good in 14/16 patients. Cannulated screws are an effective alternative in complex stabilization procedures of the cervical spine. The presented system is technically comfortable and allows safe percutaneous screw application as well as inclusion of computed navigation with high accuracy.

Approach-related complications of transthoracic spinal reconstruction procedures.

Direct surgical repair of instabilities of the anterior spinal column has gained in importance. New techniques and instruments have led to better operative results. Inspite of the growing number of interventions at the anterior spinal column only little data is available on the typical intra- and postoperative complications of these anterior approaches Between 4/1998 and 8/2002, 85 patients in two neurosurgical centres were treated using an anterolateral transthoracic approach for various lesions of the thoracic and thoracolumbar spine. We used a minithoracotomy with video-endoscopic guidance in 75 of these patients. Intra- and postoperative complications were evaluated retrospectively. Two operations had to be abandoned, in all other cases surgery was performed as planned. Postoperatively, eleven patients complained of temporary intercostal neuralgia (12.9%), two patients (2.3%) had a pulmonary insufficiency which was treated conservatively, another patient needed drainage of a pleural effusion. One intraoperative injury to the thoracic duct was treated conservatively, one hernia of the abdominal wall had to be corrected surgically. Relevant injuries to the vessels did not occur, blood loss was 520 ml on average. There was no surgical mortality; one revision surgery had to be performed because of bone graft dislocation. The rate of severe approach-related complications was 4/85 = 4.7% (two abandoned procedures, one injury to the thoracic duct, one abdominal hernia). Transthoracic anterolateral stabilisation via a minithoracotomy with video-endoscopic guidance is an effective surgical approach to treat instabilities of the anterior parts of the thoracic spine and the thoracolumbar area with low complication rates.

Results of applying ADCON-L gel after lumbar discectomy: the German ADCON-L study.

OBJECT: Failed-back syndrome is still an unsolved problem. Use of ADCON-L gel, already commercially available, has been proven to reduce postoperative scarring in animal experiments. The authors of two controlled clinical studies have also shown positive results when applying the gel. They did not, however, establish patient-oriented endpoints. The authors report a study of ADCON-L in which they focus on patient-oriented endpoints. METHODS: Patients with lumbar disc herniation were randomized to an ADCON-L-treated or control group. Therapeutic success was evaluated using the validated Hannover Questionnaire on Activities of Daily Living (FFbH) 6 months after surgery. The study took place between November 14. 1996, and April 20, 1998, in eight neurosurgical centers in Germany. A total of 398 patients was recruited; 41 patients dropped out during follow up. The mean functional FFbH score (100 points = all activities are possible without problem; 0 points = no activity is possible) was 78.5 points in the ADCON-L-treated group compared with 80 points in the control group. Furthermore, in terms of secondary outcome variables, the ADCON-L group did not have an advantage over the control group. Only the mean magnetic resonance imaging score showed a slight advantage of ADCON-L over the control group. CONCLUSIONS: The authors found no positive effect of treatment with ADCON-L gel in patients in whom one-level lumbar microdiscectomy was performed. Because of its rather large sample size and its homogeneity, the study had sufficient power to detect even small differences between the two groups.

[Epidemiology of disk surgery in Germany]. / Epidemiologie von Bandscheibenoperationen in der Bundesrepublik Deutschland.

Actually, there are no valid epidemiologic data concerning intervertebral disk surgery available for Germany. Using resources of official statistical information we estimated the incidence of inpatient and outpatient disk surgery in Germany during last 6 years: The incidence for degenerative intervertebral disk surgery in Germany is about 87 operations per 100,000 inhabitants and year. There is no significant increase in the last five years, but there is a tendency to more outpatient disk surgery. Presently 16% of disk surgery is done in a outpatient procedure. Comparing with other European countries there are similar frequencies of disk surgery, contradictory in the United States there was a huge increase of the incidence for disk surgery since 1980.

[Lumbar spinal stenosis and its surgical treatment]. / Die lumbale Spinalkanalstenose und ihre operative Behandlung.

Today lumbar spinal stenosis can stand on its own as a clinical entity that can be radiologically and clinically divided into central and lateral stenosis. Foraminal stenosis is a special form of the latter. During the period 1990-1991 we operated on 148 patients for spinal stenosis. Using a standardized questionnaire, 109 patients were evaluated on their pain and gait status 3 years after the operation. Patients with previously known spondylolisthesis or degenerative instability were excluded from the study. Forty-four out of 109 patients were free of pain, while significant reduction of pain was noted in 35/109 patients. In 19 patients, the pain remained the same or worsened postoperatively. Seventy-four out of the 109 patients had no gait disturbances, whereas only 14/109 worsened postoperatively. Six patients could walk with support and seven patients were unable to walk because of other disturbances. Because of unclear responses, the status of the remaining patients could not be completely evaluated in either group.

[Juxta-facet cysts as space-occupying intraspinal processes]. / Juxtafacettenzysten als raumfordernde intraspinale Prozesse.

Ganglionic and synovial cysts (juxta-facet cysts) causing nerve root compression are very rare. Magnetic resonance imaging is the best means of diagnosis. The treatment of choice is surgical removal of the cysts, though spontaneous remissions do occur. CT-guided aspiration of the cysts and corticosteroid injection can lead the symptoms to disappear, but only for a short time. In a retrospective study covering a period of 16.5 years, we discovered 24 juxta-facet cysts (10 ganglionic and 14 synovial cysts) with clinical symptoms in a total of 19,107 lumbar and thoracic operations performed to relieve nerve root compression: 16 cysts were located at the level L4-5,3 at the level L5-S1,2 at L3-4, and 1 each at the levels L2-3, L1-2, and T10-1. Seven patients complained of radicular pain, and the other 17 patients also had neurological deficits. Fourteen cysts were resected, and in 10 cases the lumbar disc was removed simultaneously. The average follow-up in 23 of the 24 patients was 26.6 months. Most (74%) of the patients became free of pain. Pareses disappeared in 89% and sensory deficits in 73% of cases.

[Amblyopia, refractive errors and strabismus in congenital ptosis]. / Amblyopie, Refraktionsfehler und Strabismus bei kongenitaler Ptosis.

The incidence of amblyopia in the normal population is 2-6%, whereas among patients with congenital ptosis it can be as high as 50%. We reviewed 146 cases of congenital ptosis in patients aged between 5 months and 15 years and compared them to a control group of 34 age- and sex-matched patients. In 78 children (156 eyes) reliable optotype visual acuity could be obtained. Fifty-three eyes (34%) were amblyopic. Ametropia was responsible for 34% and anisometropia for 28.3% of the amblyopia cases. In 25.4% of cases strabismus, and in 11.34% stimulus deprivation, was the reason for the development of amblyopia. Children with congenital ptosis should have retinoscopy done in cycloplegia, and refractive errors should be corrected early. Controlled patching therapy should also be started early. Since stimulus deprivation amblyopia is rare, congenital ptosis need not be corrected early in life.