Percutaneous balloon kyphoplasty with the patient under intravenous analgesia and sedation: a feasibility study.

BACKGROUND AND PURPOSE: Kyphoplasty is a minimally invasive procedure for the treatment of malignant or osteoporotic vertebral compression fractures, normally performed with the patient under general anesthesia. This may cause a therapeutic dilemma because these patients often have a very high risk for general anesthesia due to concomitant diseases. The aim of this study was to evaluate the safety and feasibility of percutaneous kyphoplasty by using IV anesthesia and sedation with midazolam and piritramide. MATERIALS AND METHODS: From June 2007 to June 2009, we prospectively included 133 patients (77 women, 56 men; mean age, 69.18 ± 11.45 years) who were referred for BKP. Kyphoplasty was always performed under fluoroscopic guidance with a biplane angiographic system by using a transpedicular or extrapedicular approach. The individual anesthesia risk was assessed by using the ASA criteria. All procedures were performed with the patient under IV anesthesia and sedation with fractionated administration of midazolam and piritramide. Pain was assessed before and after treatment by using a VAS. RESULTS: Ninety-nine patients (74.4%) had a significantly increased risk for general anesthesia (ASA score, ≥ 3). A total of 162 kyphoplasty procedures were performed. The mean amounts of midazolam and piritramide used were 11.3 ± 4.38 mg and 11.8 ± 3.98 mg, respectively. No complications related to IV anesthesia and sedation occurred. Periprocedural pain management was rated as sufficient, and all patients would undergo the procedure again. CONCLUSIONS: Percutaneous BKP with the patient under IV anesthesia and sedation with midazolam and piritramide is a safe and feasible method for treating vertebral compression fractures in patients with an increased risk for general anesthesia.

Deep brain stimulation of globus pallidus internus in a 16-year-old boy with severe tourette syndrome and mental retardation.

A 16- year-old boy with long-standing severe Tourette syndrome (TS) and mental retardation, non-responsive to complex pharmocological and behavioural treatment was selected for bilateral deep brain stimulation (DBS) of the globus pallidus internus (GPi). Pre-operative and post-operative Yale Tourette syndrome scale (YTSS) scores and several other scores were used to quantify the effect of DBS up to one year follow-up. Although subscores of the YTSS improved, the overall outcome of chronic GPi-DBS showed no substantial therapeutic effect. This finding is in contrast to markedly improved TS of the only two adolescent TS patients in whom DBS has been performed so far. In this article we discuss possible reasons for the poor therapeutic effect of GPi-DBS in our patient contributing to the on-going debate on DBS inclusion criteria for adolescent TS patients.

Surgical decompression for traumatic brain swelling: indications and results.

OBJECT: Decompressive craniectomy has been performed since 1977 in patients with traumatic brain injury. The authors assess the efficacy of this treatment and the indications for its use. METHODS: The clinical status of the 57 patients, their computerized tomography (CT) scans, and intracranial pressure (ICP) levels were documented prospectively in a standard protocol. At the beginning of the study, all patients older than 30 years were excluded. As of 1989 patients older than 40 years were excluded until 1991; since that time patients older than 50 years have been excluded. Primary brain or brainstem injury with fully developed bulbar brain syndrome, loss of auditory evoked potentials (AEPs), and/or oscillation flow in a transcranial Doppler ultrasound examination were contraindications to decompressive craniectomy. A positive indication for decompression was given in the case of progressive therapy-resistant intracranial hypertension in correlation with clinical (Glasgow Coma Scale [GCS] score, decerebrate posturing, dilating of pupils) and electrophysiological (electroencephalography, somatosensory evoked potentials, and AEPs) parameters and with findings on CT scans. Unilateral decompressive craniectomy was performed in 31 patients and bilateral craniectomy in 26 patients. In all cases, a wide frontotemporoparietal craniectomy was followed by a dura enlargement covered with temporal muscle fascia. The outcomes of the treatment were surprisingly good. Only 11 patients (19%) died, three of whom died of acute respiratory disease syndrome. Five patients (9%) survived, but remained in a persistent vegetative state; six patients (11%) survived with a severe permanent neurological deficit, and 33 patients (58%) attained social rehabilitation. Two patients (3.5%) did not have a follow-up examination. The GCS score on the 1st day posttrauma and the mean ICP turned out to be the best predictors for a good prognosis. The results demonstrate the importance of decompressive craniectomy in the treatment of traumatic brain swelling. CONCLUSIONS: Surgical decompression should be routinely performed when indicated before irreversible ischemic brain damage occurs.