Isolated upper buttock pain provoked by L5 nerve root compression - a case report.

Nerve root compression in lumbar spine may be associated with low back pain. However, isolated gluteal pain without any radicular symptoms in patient with lateral recess stenosis is rather unexpected and to our knowledge was not reported in the literature. A CASE REPORT: We present a patient that suffered from isolated upper buttock pain without any radicular component. A series of selective injections under image guidance was performed in order to determine the source of patient's pain which turned out to be L5 nerve root compression. Following microsurgical decompression our patient remained pain free in a 1-year follow-up. Possible mechanisms underlying lumbar disc herniation-related low back pain and its management strategy are discussed. CONCLUSIONS: Although very rare, L5 nerve root compression may manifest as exclusively axial pain without any radiculopathy. In such cases, L5/S1 transforaminal injection with Xylocaine should be performed in order to confirm the origin of pain. Surgeons should not be afraid to propose microsurgical decompression in such a case scenario.

Intra-operative fluorescein videoangiography-related nephrotoxicity in intracranial aneurysm surgery: Single center, observational cohort study.

OBJECTIVES: Intra-operative fluorescein video angiography (FL-VA) has been given increasing attention recently and several studies reported its high utility in neurovascular surgery. The aim of this study was to evaluate the safety of FL-VA in a prospective, single-center cohort of patients operated due to cerebral aneurysms. PATIENTS AND METHODS: This is an observational cohort study including 150 patients operated due to intracranial aneurysms. The study group consisted of 70 consecutive patients operated with the use of fluorescein video angiography. Post-operative acute kidney injury (AKI) occurrence as well as systemic adverse reactions were reported and further compared with 80 matched controls where FL-VA was not used. Statistical analysis was performed using non-parametric tests (Fisher's exact test). RESULTS: Post-operative AKI was observed in 17,1% of patients in the study group with only half presenting with acute functional impairment. All of these patients presented initially due to aneurysm rupture. Pre-existing renal dysfunction and hypertension occurred in 16,7% and 33,3%, respectively. No systemic complications following FL-VA were reported. When compared to matched controls, no statistically significant difference regarding AKI occurrence was observed between these two patient populations. CONCLUSION: Intra-operative fluorescein video angiography proved to have a good safety profile in our cohort. The results of this study suggest that post-operative acute kidney injury observed in patients with subarachnoid hemorrhage is not related to fluorescein use.

Predictors of Intraoperative Aneurysm Rupture, Aneurysm Remnant, and Brain Ischemia following Microsurgical Clipping of Intracranial Aneurysms: Single-Center, Retrospective Cohort Study.

BACKGROUND AND STUDY AIMS: Complete microsurgical clip occlusion of an aneurysm is one of the most important challenges in cerebrovascular surgery. Incorrect position of clip blades as well as intraoperative aneurysm rupture can expose the patient to serious complications such as rebleeding in case of aneurysm remnant and cerebral ischemia in case of occlusion of branching arteries or perforators. The aim of this study was to identify independent predictors of surgery-derived complications (aneurysm remnant and brain ischemia) as well as intraoperative aneurysm rupture in an institutional series of patients. MATERIAL AND METHODS: This is a single-institution, retrospective cohort study including 147 patients with 162 aneurysms that were selected for microsurgical clipping due to intracranial aneurysm in a 5-year period. Bivariate and multivariate analyses were performed to identify independent predictors among demographic, clinical, and radiographic factors. RESULTS: Increasing aneurysm size with a cutoff value at 9 mm (p = 0.009; odds ratio [OR]: 0.644) and irregular dome shape (p = 0.003; OR: 4.242) were independently associated with brain ischemia and aneurysm remnants that occurred in 13.6 and 17.3% of patients in our group, respectively. Intraoperative rupture was encountered in 27% of patients and its predictors were patient's age (p = 0.002; OR: 1.073) and increasing aneurysm size with a cutoff value at 7 mm (p = 0.003; OR: 1.205). CONCLUSION: Aneurysm size, patient's age, and irregular dome shape were the most important risk factors of aneurysm remnant, brain ischemia, and intraoperative aneurysm rupture in our series of patients. We were not able to define a cutoff value for patient's age, but our results showed that with increasing age the risk of intraoperative aneurysm rupture increased.

Intraoperative fluorescein video angiography in intracranial aneurysm surgery: single-center, observational cohort study.

The aim of this study was to compare the incidence of postoperative, surgery-related complications in patients where fluorescein video angiography (FL-VA) was performed with those operated without intraoperative verification. This is an observational cohort study including 97 patients who were selected for microsurgical clipping due to intracranial aneurysm. First 52 patients enrolled in the study were operated prior to introduction of fluorescein fluorescence in our surgical workflow. These patients were considered as controls. The study group consisted of 45 consecutive patients operated with the use of fluorescein video angiography and by the same surgical team. Outcomes in both groups were compared using non-parametric test (Mann-Whitney U). Intraoperative fluorescein video angiography revealed aneurysm remnant or inadvertent vessel occlusion in 17.8% of patients. Following clip reposition, a repeated FL-VA was performed to confirm restoration of blood flow and/or complete aneurysm obliteration. Intraoperative findings were later confirmed using computed tomography angiography (CTA). None of the patients in our study group developed surgery-related complications; whereas in the control group, aneurysm remnant was discovered in 7.7%, brain ischemia in 9.6% and both of the latter in 5.8% of patients. Difference in treatment-related outcome was statistically significant (p < 0.05). Intraoperative fluorescein video angiography successfully identified aneurysm residual and adjacent artery occlusion leading to excellent outcome following clip reposition.

Superior Hypophyseal Artery Ruptured Aneurysm in a 5-Month-Old Child Presenting as an Acute Subdural Hematoma: A Case Report.

INTRODUCTION: We present a very rare case of ruptured superior hypophyseal artery (SHA) aneurysm that presented as an acute subdural hematoma (SDH) discussing its initial presentation, diagnosis, and treatment modalities. To our knowledge it is one of very few if any cases of a ruptured aneurysm in infants regarding that specific vascular location. CASE REPORT: A 5-month-old boy was referred to our department due to acute SDH over the right cerebral hemisphere without significant mass effect nor hydrocephalus. Further evaluation revealed a right internal carotid artery (ICA) aneurysm arising from the SHA segment. Microsurgical clip ligation using a fenestrated, angled clip was performed with simultaneous subdural clot removal and proximal control of the ICA dissected in the neck. Our patient made an excellent recovery without any complicating features. CONCLUSION: Surgical management seems to be a better option in this subgroup of patients given the long life expectancy and durability of microsurgical clip ligation. We believe that our brief case report would add some insight into the management of this rare subgroup of patients, leading to better decision-making and outcome.

Predicting conservative treatment failure in patients with lumbar disc herniation. Single center, case-control study.

OBJECTIVES: The aim of this study was to identify independent predictors of conservative treatment failure in patients presenting due to lumbar disc herniation-associated low back pain and sciatica. PATIENTS AND METHODS: This is a single institution, case-control study including 240 patients that were selected for microsurgical or conservative treatment due to lumbar disc herniation in a 2,5-year period. Bivariate and multivariate analyses were performed in order to identify independent predictors among demographic, clinical and radiographic factors. RESULTS: Statistically significant differences were observed between conservatively and surgically managed groups in bivariate analysis. Logistic regression models further revealed that leg paresthesia (p =  0,003; OR = 5,136) and percentage of spinal canal stenosis ratio (p < 0,001; OR = 1,055) had the strongest, independent correlation with conservative treatment failure in our cohort. Back-to-leg ratio did not reach statistical significance although it proved a strong correlation in bivariate analysis (p < 0,001, Cramér's V = 0,53). CONCLUSION: Increasing % canal compromise ratio (cut-off value 23%) and co-occurrence of leg paresthesia were the most important risk factors for surgery in our series of patients.

Intraoperative fluorescein videoangiography in cerebral aneurysm surgery - a preliminary study.

One of the most important challenges in intracranial aneurysm surgery is safe and correct clip deployment. Various methods have been developed in order to improve surgeon's intraoperative confidence and provide real-time information about the efficacy of clipping. Sodium fluorescein video angiography, however, was not well studied so far. AIM: The aim of the study was to evaluate the accuracy of FLuorescein Video Angiography (FL-VA) performed intraoperatively during intracranial aneurysm surgery in demonstrating complete occlusion of the aneurysm sac while preserving the patency of parent, branching, and perforating arteries. MATERIALS AND METHODS: This is a prospective study based on a series of 41 consecutive patients harboring 43 aneurysms. All patients underwent surgical clipping followed by intraoperative, intravenous administration of 200 mg bolus of sodium fluorescein dye. After surgery, CTA was performed in order to identify any aneurysm remnant or signs of cerebral ischemia in the territory of branching arteries adjacent to clip. RESULTS: Intraoperative FL-VA led to clip reposition in 16,3%. This technology is very simple to use, cost-effective and intuitive in terms of interpretation of real-time, high quality images derived intraoperatively without the need to interrupt microsurgery. It provides a surgeon with additional confidence and real-time data enabling to adjust clip position in order to avoid potentially severe complications. CONCLUSIONS: Based on our preliminary experience we believe that fluorescein video angiography has a safe profile and is very useful in cerebral aneurysm surgery.

Factors determining the best surgical exposure and safe clip positioning in surgical treatment of anterior communicating artery (AComA) aneurysms - particular significance of AComA complex rotation in the axial plane.

INTRODUCTION: The aim of this study was to evaluate whether Anterior Communicating Artery (AComA) complex rotation in axial plane may influence the ease of surgical exploration in this region and safety of clip positioning when left vs right-sided approach is compared. MATERIALS AND METHODS: This is a retrospective study based on analysis of patients operated due to AComA aneurysm, both ruptured and unruptured. AComA complex position in relation to coronal plane was evaluated using 3D-CTA VR reconstructions. Next, comparison between surgical approach from the side where A1-A2 junction (angle) was located anterior and posterior to coronal plane was performed in relation to surgical difficulties and intra- and postoperative complications. RESULTS: Subgroup statistical analysis revealed that there is a strong and statistically significant correlation between AComA complex rotation and surgical difficulties expressed by the need of repeated temporary clip application and brain transgression. When anterior vs posterior angle side approach was compared in relation to surgical difficulties and complications, there was a statistically significant difference with strong correlation (p < 0.05) in favour of posterior angle side approach. Interestingly, in 72.7% and 45.5% of patients that were operated from the side where A1-A2 junction was located posterior to coronal plane, the approach was performed form the side of a non-dominant A1 and aneurysm dome projection side, respectively. CONCLUSIONS: Despite its limitations, our results suggest that microsurgical clipping strategy of AComA aneurysms should at least include AComA complex rotation in axial plane, besides well acknowledged factors, when deciding from which side these lesions will be approached.

Clinical application of 3D pre-bent titanium implants for orbital floor fractures.

INTRODUCTION: Orbital structures are affected in approximately 40% of all cases of craniofacial trauma. Changes in the bony orbital dimensions can alter the function of intraorbital contents and lead to serious complications. The unique anatomy of the orbit and the resulting surgical approaches make the process of fitting and aligning implants difficult, time consuming and operator dependent. It is now possible to make relatively inexpensive anatomical models on the basis of computed tomography images, using rapid prototyping. Such models can be used as templates to form titanium mesh implants, which are then used in the reconstruction of orbital floor defects. MATERIAL AND METHODS: Six patients with facial trauma were included in this study. First, 3D virtual models and then physical models were created. These were used as templates to shape the titanium mesh and then intraoperatively as guides to aid correct implant placement in the orbit. RESULTS: Significant improvement resulted in three cases and total recovery in three cases. CONCLUSION: It is financially viable to build anatomical models, on the basis of CT studies, that can be used in the repair of orbital floor fractures.

[Role of proteoglycans and glycosaminoglycans in the intervertebral disc degeneration]. / Rola glikozaminoglikanów i proteoglikanów w procesie degeneracji krazków miedzykregowych.

Proteoglycans and glycosaminoglycans are the main components of the extracellular matrix of the nucleus pulposus. Intervertebral disc degeneration due to aging and excessive mechanical loads results in adverse quantitative and structural changes to the macromolecules. Metalloproteinases induced by inflammatory mediators play a key role in degrading proteoglycans. Progressive matrix breakdown decreases water content in the disc. Dehydration compromises disc cells function and impairs resistance to compression. Biochemical changes may result in disc prolapse. Modifying the metabolism of proteoglycans and glycosaminoglycans might be an effective therapeutic strategy.

[Intraoperative assessment of cognitive and executive functions in patients with brain tumors]. / Sródoperacyjne badanie wybranych funkcji poznawczych i wykonawczych u pacjentów z guzem mózgu.

BACKGROUND AND PURPOSE: The aim of this paper was to evaluate the usefulness of selected methods of intraoperative neuropsychological assessment. In order to investigate the influence of the direct cortical stimulation and tumor resection on the patients' intraoperative performance, we examined selected areas of cerebral cortex involved in cognitive activity in patients undergoing awake craniotomy for brain tumors. MATERIAL AND METHODS: The analyzed group consisted of 21 patients (11 men, 10 women) with tumors located in eloquent areas of the left hemisphere. All patients had intact understanding of speech and relatively minor neurological deficits. We applied both experimental methods as well as certain standardized tests (WAIS-R, AVLT) for the investigation of verbal and nonverbal functions. The tests were performed during direct cortical stimulation and tumor resection, and also before and one week after the operation. RESULTS: Verbal areas were identified in 10 patients, sensorimotor strip in 3, whereas both of them in 3. Even though in 5 out of 21 subjects we were unable to identify the eloquent cortex, there was no difference between pre- and postoperative assessment in these patients. Similarly, there was no statistically significant difference in pre- and postoperative tests among patients with successful cortical mapping. CONCLUSIONS: We showed that the presented methods of intraoperative assessment of cognitive activity were useful and appropriate for the identification of the eloquent areas of the brain.

[Supplementation of cranial defects by an autologous bone flap stored in the abdominal wall]. / Uzupelnianie ubytków kosci pokrywy czaszki autologicznym platem kostnym przechowywanym w powlokach brzucha.

BACKGROUND AND PURPOSE: The aim of this paper is to present an alternative method of cranioplasty with the use of an autologous cranial bone flap stored between primary and restorative surgery in the subcutaneous pocket in the lateral hypogastric region. MATERIAL AND METHODS: Between January 1999 and April 2002, in the Department of Neurosurgery of Medical University of Lódz we performed 36 procedures of the bone flap implantation into the abdominal subcutaneous fat tissue. These procedures followed craniectomy, mainly in cases of acute subdural hematomas and ruptured intracranial aneurysms. RESULTS: After storage, the bone flap was reimplanted in 28 patients. The mean time between operations was 14 days (range 8-53 days). In the cranioplasty group we had only one infection of the bone flap. Among patients excluded from the bone flap restoration we observed one inflammatory complication in the abdominal wall and one subcutaneous hematoma requiring evacuation. CONCLUSIONS: In our opinion, the presented method of the cranial defect's supplementation may be competitive to procedures utilizing synthetic prostheses in the population of patients for whom reimplantation of the bone flap will be expected in 2-3 months after the primary operation. Advantages of the procedure are: the autologous bone graft, the excellent cosmetic effect, low costs of the procedure and low rate of inflammatory complications.

[Awake craniotomy and brain mapping for eloquent cortex in patients with supratentorial tumors: a preliminary report]. / Sródoperacyjne wybudzanie i mapowanie elokwentnych okolic mózgu u pacjentów z guzami nadnamiotowymi--doniesienie wstepne.

Malignant brain tumours are incurable at present. Since none of the hitherto used treatment methods allows to significantly extend these patients' survival time, the basic aim is to improve their quality of life. Intraoperative brain mapping seems to be an approach enabling to minimize the risk of irreversible damages to functionally important structures of the brain. In the Department of Neurosurgery of the Medical University of Lódz awake craniotomy with stimulation of eloquent cortex was attempted from May 1999 to July 2000 in 13 patients aged 16 to 77 years. In two patients the attempt of intraoperative awakening was unsuccessful. In 8 out of the 11 awakened patients intraoperative brain mapping had a significant effect on the course of surgery (i.e. on the resection magnitude and "safe corridor"). Out of six patients with tumors situated in the neighbourhood of motor cortex--one developed a severe and permanent paresis of the upper limb. On the grounds of the literature and the authors' own experience an algorithm of awake craniotomy and intraoperative brain mapping was worked out.