Endoscope-assisted interlaminar removal of an ependymoma of the cauda equina.

In oder to reduce surgical trauma to the lumbar spine during a multilevel laminectomy procedure we performed a multilevel, bilateral and interlaminar approach, with microsurgical and endoscopic techniques for removal of a large ependymoma of the lumbar spine in a 33-year-old female patient. Complete tumor removal has been achieved, while at the same time, the major elements that form the posterior spinal column could be preserved. The follow-up time is 4 years.

[Intrathecal administration of triamcinolone in treatment of pain after discectomy]. / Die intrathekale Gabe von Triamcinolon in der Behandlung von Schmerzen nach Diskektomien.

The efficacy and compatibility of intrathecal corticoid therapy was studied in a series of 160 patients (out of a total collective of 3000 patients operated on over a 5-year period for disc herniation) suffering from continuing pain in the first 5 days following discectomy. 80 patients received triamcinolone acetonide in crystalline suspension (Volon A 80, 2.0 ml) intrathecally via lumbar puncture on the 5th postoperative day (group A). The remaining 80 patients acted as controls (group B). Additionally, all patients were treated by conservative means. On the 6th, 8th and 12th postoperative day they all had to classify their wellbeing according to a 5-grade pain scale. On the 6th day 75% of group A patients assessed their symptoms as belonging to the favourable grades 1 and 2 (completely free of pain or slight remaining complaints), whereas only 5% of the control group did so (p < 0.0003). On the 8th and 12th postoperative day this difference was not as significant. All patients were examined again 4 weeks after discharge from the hospital. At this time the difference between the two groups was not statistically significant (p < 0.12). No general systemic effects due to intrathecal corticoid administration were recorded. However, in 11 cases (13%) postpunctional signs of greater or lesser severity, reaching from slight to severe headache with nausea and vomiting occurred. All these symptoms disappeared at the latest within 1 week and would--in our opinion--be avoidable by correct lumbar puncture technique. In general, this study revealed that intrathecal triamcinolone administration is highly effective in the relief of postdiscectomy pain and may reduce the period of postoperative pain significantly.

Quadriplegia after lumbar disc surgery. A case report.

STUDY DESIGN: Case report. OBJECTIVE: To report a case of quadriplegia after surgery in the prone position for a herniated lumbar disc. SUMMARY OF BACKGROUND DATA: Ischemia in the vascular territories of the vertebral arteries after back surgery in the prone position is rare. Degenerative changes of the cervical spine or decreased blood flow to the head with mechanical vessel obstruction during extreme neck movements, systemic hypotension, and thromboembolism have mostly been implicated in the pathogenesis. METHODS: The case of a 33-year-old man undergoing surgery for an unilateral single level disc herniation at L4-L5 is presented. Within a few hours after surgery he developed quadriplegia and signs of occipital lobe dysfunction. He underwent magnetic resonance imaging investigation. Therapy included arterial blood pressure control, low molecular dextran, dexamethasone, bladder catheterization, and physiotherapy. RESULTS: Magnetic resonance imaging demonstrated intramedullary ischemic changes in the cervical spinal cord and at the borderline between anterior and posterior circulation. Outcome after 2 years is fair regarding the severe initial deficit-the patient walks alone with a cane and bladder function is under control. He is employed in a sedentary job. CONCLUSIONS: The authors believe that a temporary mechanical occlusion of a vertebral artery led to stasis, formation of thrombi, and subsequent embolism in the vertebrobasilar vascular territory. Extreme head rotation and neck extension is to be avoided in the prone position.

The interface between ionomer cement and bone in the porcine cervical spine.

The interface between bone and ionomer cement has been studied in twelve young adult pigs 1-6 months after anterior cervical discectomy, removal of adjacent end plates and grafting of the bone defect with ionomer cement. Methods used to study the interface were fluorescence microscopy, scanning electron microscopy, electron microprobe analysis and radiological investigation. The interface in all animals consisted of collagenous tissue. The amount of collagenous fibres was related to the amount of residual movement within the motion segment: animals undergoing anterior plating after reconstruction of the bone defect presented with more or less compactly organized collagenous tissue. Sequential fluorochromic marking of osteoid formation revealed a vital bone bed around the interface but no signs of direct bone apposition to the ionomer cement plug. No signs of toxicity or graft rejection were noted. Ionomer bone cement contrary to experimental and clinical experience induces the formation of a connective tissue layer of different density in the porcine cervical spine.

Management of spontaneous extramedullary spinal haematomas: results in eight patients after MRI diagnosis and surgical decompression.

Spinal cord compression due to extradural and subdural haemorrhage is a neurosurgical emergency. Differences in clinical presentation in relation to localisation of the haematoma, value of MRI as a diagnostic tool, surgical treatment, and prognosis were investigated in a retrospective case series of eight patients with extradural (n = four) and subdural (n = four) haematomas. Results of MRI were compared with operative findings and proved to be of high sensitivity in defining the type of bleeding and delineating craniocaudal extension and ventrodorsal location. Surgical treatment by decompressive laminectomy, haematoma evacuation, and postoperative high dose corticosteroids resulted in resolution of symptoms in five patients and improvement in the clinical situation in two patients. One patient with a chronic subdural haematoma had a second operation because of arachnoidal adhesions. One patient presented with a complete cord transection syndrome due to an acute subdural haematoma and remained paraplegic. It is concluded that prompt, reliable, and non-invasive diagnosis by MRI leads to efficient surgical treatment and a favourable outcome in this rare condition.

[Prognosis of epidural hematoma: is emergency burr hole trepanation in craniocerebral trauma still justified today?]. / Prognose nach epiduralem Hämatom: ist die notfallmässige Bohrlochtrepanation beim Schädel-Hirn-Trauma heute noch zeitgemäss?

We made a retrospective study of the records of 80 patients with epidural haematoma, to investigate whether delay between injury and surgery and neurological status upon admission affect outcome after 3-6 months. Outcome was classified on a four-grade scale, grade 1 meaning full recovery and grade 4, death. Overall mortality was 13%. Patients operated on within 7 h after injury made a full recovery in 52%, and mortality in this group was 6%. Patients operated on between 7 h and 14 h after injury made a full recovery in 20%; mortality was 16%. Among the patients who were not comatose on admission a good outcome was achieved in 55% and mortality was 3%. The outcome in patients who were comatose on admission was rated grade 1 in 15% and grade 4 in 25%. The proportion of comatose patients and the mortality were higher in patients transferred from general hospitals. Textbook signs of epidural haematoma are not reliable aids to diagnosis and localization; for example a lucid interval occurred in only 58% of our patients. It is concluded that emergency burr hole trepanation might improve the outcome in patients showing signs of brain stem dysfunction after head injury, but prior computed tomography is necessary to guide such an intervention at the district hospital level.

[Ischemic lesions in the vertebral artery blood flow area as a rare complication of lumbar disk surgery]. / Ischämische Läsionen im Vertebralisstromgebiet als seltene Komplikation der lumbalen Diskuschirurgie.

We report on the case of a 61-year old man who developed a reversible Brown-Sequard syndrome immediately after an uncomplicated lumbar discectomy. Magnetic resonance imaging showed ischaemic lesions in the upper cervical medulla, the caudal part of the medulla oblongata, and in the cerebellum. Vertebral artery compression due to spondylosis and hyperflexion of the cervical spine during operation is discussed as a possible pathogenetic mechanism.

[Retroperitoneal vascular injuries as a complication of lumbar disc operation]. / Retroperitoneal Gefässverletzungen als Komplikation von lumbalen Diskusoperationen.

We describe 2 cases of retroperitoneal hematoma after lumbar disc surgery following injury to retroperitoneal vessels. One patient sustained a partial tear of the right common iliac artery during left L4/5 discectomy, the other a complete tear of the lowest lumbar artery during left L5/S1 discectomy. Both patients developed hypovolemic shock 4-5 hours postoperatively, with acute abdominal symptoms and signs; the former patient also showed signs of ischemia of the right lower extremity. Both recovered completely after surgical intervention with vascular repair and evacuation of the retroperitoneal hematoma.

[Cerebellar hemorrhage and cerebellar infarct: retrospective study of 125 cases]. / Kleinhirnblutungen und Kleinhirninfarkte: retrospektive Studie von 125 Fällen.

In a retrospective study of 125 patients, symptoms, diagnosis, and clinical course of 64 cases of cerebellar infarction and 61 cerebellar hemorrhage were studied retrospectively. Neurologically, cerebellar signs were present in 50% of hemorrhages and 7%, of infarctions, while 50% of patients with cerebellar hemorrhage and 37% of patients with cerebellar infarction showed brain stem symptoms or cranial nerve deficits; at least slight disturbance of consciousness was present in all patients. The state of consciousness, as estimated by the Innsbruck Coma Scale, together with diagnostic imaging (CT and/or MRT) allowed precise indication for surgical intervention. Over-all lethality was 11% for cerebellar infarction, and 31%, for cerebellar hemorrhage. Comparison of clinical outcome and state of consciousness at time of surgery suggests, that decompressive craniotomy should be performed even in deeply comatose patients with signs of decerebration.

[Actinomycosis infection of the cerebellum]. / Aktinomykose-Infektion im Kleinhirn.

The case is presented of a 37-year-old male with a cerebellar abscess due to Actinomyces israelii. The patient was admitted after dental surgery because of fever and symptoms indicative of raised, intracranial pressure. No abnormalities were detected in peripheral blood and cerebrospinal fluid. CT scan revealed a space-occupying lesion in the left cerebellar hemisphere with perifocal oedema and occlusive hydrocephalus. After emergency external ventriculostomy complete removal of the mass was achieved in a two-stage surgical procedure. Culture of the pus under anaerobic conditions resulted in a growth of Actinomyces israelii, Peptostreptococcus anaerobius and Bifidobacterium adolescentis. A 20-day regimen of antibiotics including penicillin G 10 million U x 3/d and clindamycin 900 mg x 3/d was administered. The patient made a full recovery. Pathogenesis and therapeutic principles of CNS infections due to Actinomyces israellii are discussed.

[Chronic subdural hematoma as a cause for blindness]. / Ein chronisches Subduralhämatom als Erblindungsursache.

The uncommon complication of bilateral blindness resulting from a decompressive neurosurgical procedure is presented by the case of a 51-year old patient suffering from a traumatic chronic subdural haematoma. A breakdown of the altered vasoregulation of the optic nerves due to papilledema at the time of intracranial pressure drop is supposed to be the etiological background of optic atrophy and consequent amaurosis. The causal relationship of accident trauma and blindness in the presented case is pointed out.

[Surgical treatment of glossopharyngeal neuralgia]. / Die chirurgische Behandlung der Glossopharyngeusneuralgie.

Glossopharyngeal neuralgia is a rare disease which is characterized by severe paroxysmal pain attacks in the distribution of the 9th cerebral nerve. Although uncommon, the condition has to be considered in the differential diagnosis of various craniofacial neuralgias. The purpose of this study was to describe 3 cases of glossopharyngeal neuralgias and to discuss its diagnosis and therapy. Various surgical therapeutic procedures have been described, including neurotomy of the glossopharyngeal nerve in the frontal neck, thermocoagulation of Andersch's ganglion, and para-pontine neurotomy (Dandy). Because of its good results and low incidence of recurrences, microvascular decompression (Jannetta) is considered the procedure of choice.

[Surgical treatment of cervical intervertebral disk displacement]. / Die chirurgische Behandlung des zervikalen Bandscheibenvorfalls.

Between the years 1976 und 1989 147 patients were operated on cervical disc herniation at the Neurosurgical Clinic of Innsbruck. 122 of these cases underwent a posterior approach according to Frykholm, 25 patients were treated by an anterior approach according to Cloward and Smith and Robinson, respectively. All patients received a descending myelography followed by a CAT-Scan of the questionable cervical segments the latter was available. In patients with disc herniation and only mild degenerative changes of the cervical spine a dorsal foraminotomy was chosen whereas the cases with nerve root compressions primarily due to spondylosis the ventral approach was preferred. Patients revealed a convincing benefit of motoric deficits after foraminotomy whereas disturbances of sensibility showed minor improvement either by ventral or posterior approach.

[Experiences with Kahn's method of dentatotomy]. / Erfahrungen mit der Dentatotomie nach Kahn.

Between 1980 and 1990, 37 patients with cervical spondylotic myelopathy and syringomyelia underwent posterior decompression by laminectomy and dentatotomy. The preoperative symptoms are compared with the postoperative status. Spasticity and pyramidal signs were reduced. In our opinion, Kahn's indication for dentatotomy as described in 1946 is obsolete today. However, we believe that after extensive decompressive laminectomy an additional mobilising effect is recommendable, so that Kahn's operation is still of relevance as an additional procedure in the treatment of this condition.

[Eosinophilic bone granuloma in an 8-month-old infant]. / Ein eosinophiles Knochengranulom bei einem 8 Monate alten Säugling.

A solitary eosinophilic granuloma in an 8 month-old infant is presented. The tumour, which had penetrated bone dura, but spared the brain tissue was radically excised. This case shows an unusually low age of presentation of this rare disease, and an unusual endocranial extension of the tumour. If an infantile eosinophilic granuloma is suspected, then computerized tomography should always be performed.

[Depressed fracture of the calvaria]. / Die Impressionsfraktur am Schädeldach.

This study is based on 147 depressed fractures of the calvaria. 60% of the diagnosed and treated cases were compound depressed fractures. Of the 147 patients 12 developed intracerebral, epidural and subdural hematomas. 3 persons developed infections. Of course the decision to institute prophylactic anticonvulsive therapy we only found 7 cases of posttraumatic epilepsy. Because of our experience in treatment of the depressed fracture we divide a consequent and rapid diagnosis by X-rays in combination with modern computer-tomography.