External Ventricular Catheter Placement: How to Improve.

This cadaveric study outlines the efficiency, safety and precision of cerebral ventricular catheter placement comparing classical freehand technique using anatomical landmarks, neuronavigation and XperCT-guided assistance.

Correlation of pain, functional impairment, and health-related quality of life with radiological grading scales of lumbar degenerative disc disease.

BACKGROUND: It is generally believed that radiological signs of lumbar degenerative disc disease (DDD) are associated with increased pain and functional impairment as well as lower health-related quality of life (HRQoL). Our aim was to assess the association of the Modic and Pfirrmann grading scales with established outcome questionnaires and the timed-up-and-go (TUG) test. METHODS: In a prospective two-center study with patients scheduled for lumbar spine surgery, visual analogue scale (VAS) for back and leg pain, Roland-Morris Disability Index, Oswestry Disability Index and HRQoL, as determined by the Short-Form (SF)-12 and the Euro-Qol, were recorded. Functional mobility was measured with the TUG test. Modic type (MOD) and Pfirrmann grade (PFI) of the affected lumbar segment were assessed with preoperative imaging. Uni- and multivariate logistic regression analysis was performed to estimate the effect size of the relationship between clinical and radiological findings. RESULTS: Two hundred eighty-four patients (mean age 58.5, 119 (42 %) females) were enrolled. None of the radiological grading scales were significantly associated with any of the subjective or objective clinical tests. There was a tendency for higher VAS back pain (3.48 vs. 4.14, p = 0.096) and lower SF-12 physical component scale (31.2 vs. 29.4, p = 0.065) in patients with high PFI (4-5) as compared to patients with low PFI (0-3). In the multivariate analysis, patients with MOD changes of the vertebral endplates were 100 % as likely as patients without changes to show an impaired TUG test performance (odds ratio (OR) 1.00, 95 % confidence interval (CI) 0.56-1.80, p = 0.982). Patients with high PFI were 145 % as likely as those with low PFI to show an impaired TUG test performance (OR 1.45, 95 % CI 0.79-2.66, p = 0.230). CONCLUSIONS: There was no association between established outcome questionnaires of symptom severity and two widely used radiological classifications in patients undergoing surgery for lumbar DDD.

[Cervical disc herniation--diagnosis and treatment]. / Hernie discale cervicate--diagnostic et prise en charge.

A cervical disc herniation (CDH) is a frequently encountered pathology in primary care medicine. It may give rise to a compression of a nerve root (a radiculopathy, with or without sensory-motor deficit) or of the spinal cord (myelopathy). The majority of CDHs can be supported by means of a conservative treatment. When a radiculopathy is found and a clinico-radiological correlation is present, a moderate neurological deficit appears suddenly, or if it is progressive under conservative treatment or if pain is poorly controlled by well-conducted conservative treatment performed during 6 to 8 months, surgery is then recommended. A symptomatic cervical myelopathy is, by itself, an indication for a surgical treatment.

[Minimally invasive spine surgery: past and present]. / Chirurgie du rachis lombaire minimalement invasive: passé et present d'une technique pleine d'avenir.

In the early twentieth century, the understanding of spine biomechanics and the advent of surgical techniques of the lumbar spine, led to the currently emerging concept of minimal invasive spine surgery, By reducing surgical access, blood loss, infection rate and general morbidity, functional prognosis of patients is improved. This is a real challenge for the spine surgeon, who has to maintain a good operative result by significantly reducing surgical collateral damages due to the relatively traumatic conventional access.

Clinically relevant complications related to posterior atlanto-axial fixation in atlanto-axial instability and their management.

BACKGROUND: The Magerl transarticular technique and the Harms-Goel C1 lateral mass-C2 isthmic screw technique are the two most commonly used surgical procedures to achieve fusion at C1-C2 level for atlanto-axial instability. Despite recent technological advances with an increased safety, several complications may still occur, including vascular lesions, neurological injuries, pain at the harvested bone graft site, infections, and metallic device failure. METHODS: We retrospectively analyzed all patients (n=42 cases) undergoing a Harms-Goel C1-C2 fixation surgery with polyaxial C1 lateral mass screws and C2 isthmic screws at two different institutions between 2003 and 2012 and report clinical and radiological complications. One patient was lost to follow-up. The mean follow-up of the remaining 41 patients was 18.7 months (range 12-90). A clinically relevant complication was defined as a complication determining the onset of a new neurological deficit or requiring the need for a revision surgery. RESULTS: A total of 14 complications occurred in 10 patients (24.4% of 41 patients). Greater occipital nerve neuralgia was evident in 4 patients (9.8%). All but one completely resolved at the end of the follow-up. Persistent neck pain was reported by 3 patients (7.3%), hypoesthesia by 1 patient (2.4%), and anesthesia in the C2 area on both sides in 1 patient (2.4%). Furthermore, a superficial, a deep, and a combined superficial and deep wound infection occurred in 1 patient each (2.4%). One patient (2.4%) had pain at the iliac bone graft donor site for several weeks with spontaneous resolution. A posterior progressive intestinal herniation through the iliac scar was seen in 1 case (2.4%), which required surgical repair. No vascular damages occurred. Altogether, 5/41 patients (12.2%) had a clinically relevant complication including 4 patients necessitating a revision surgery at the C1-C2 level (9.8%). CONCLUSIONS: Atlanto-axial fixation surgery remains a challenging procedure because of the proximity of important neurovascular structures. Nevertheless, on the basis of our current experience, the C1 lateral mass-C2 isthmic screw technique appears to be safe with a low incidence of clinically relevant complications. Postoperative C2 neuralgia, as the most frequent problem, is due to surgical manipulation during preparation of the C1 screw entry point.

[Lumbar disc herniation--diagnosis and treatment]. / Hernie discale lombaire--diagnostic et prise en charge.

A lumbar disc herniation (LDH) is a condition frequently encountered in primary care medicine. It may give rise to a compression of one or more nerve roots, which can lead to a nerve root irritation, a so-called radiculopathy, with or without a sensorimotor deficit. The majority of LDHs can be supported by means of a conservative treatment consisting of physical therapy, ergotherapy, analgetics, anti-inflammatory therapy or corticosteroids, which may be eventually administered by infiltrations. If a clinico-radiological correlation is present and moderate neurological deficit appears suddenly, if it is progressive under conservative treatment or if pain is poorly controlled by well-conducted conservative treatment performed during four to six months, surgery is then recommended.

Calcifying pseudoneoplasms of the neuraxis (CAPNON): clinical features and therapeutic options.

INTRODUCTION: Calcifying pseudoneoplasms of the neuraxis (CAPNON) are rare, slow-growing lesions occurring anywhere in the central nervous system (CNS). Since their first description in 1978, only 39 cases have been reported in the literature. METHODS: The cases of two patients with histopathologically verified diagnoses of CAPNON are presented. Thereafter, we review all reports published so far with respect to study type, number of patients, anatomical area (intracranial, spinal, or both), clinical presentation, radiological presentation, therapy, duration of follow-up, incidence and type of complication, and outcome. Furthermore, current recommendations for the management of spinal and cerebral CAPNON are discussed. RESULTS: A total of 19 retrospective articles were identified and selected for review: 6 case series (31.6 %) and 13 reports of single cases (68.4 %). The 19 articles and our two additional cases added up to a total of 19 patients with spinal CAPNON and 22 patients with intracranial CAPNON. All patients were treated surgically. A follow-up was provided in 13 patients with spinal (68.4 %) and in 16 patients with intracranial CAPNON (72.7 %), respectively. The follow-up showed no signs of recurrence in 12 of 13 patients with spinal CAPNON (92.3 %) and in 15 of 16 patients with intracranial CAPNON (93.7 %). One-tailed Fisher's exact test revealed no significant difference between complete and incomplete resection in terms of disease recurrence (spinal: p = 0.6842; intracranial: p = 0.3749). Analysis of the literature did not reveal any deaths directly associated with CAPNON. CONCLUSIONS: Calcifying pseudoneoplasms are rare benign lesions of the CNS of yet unknown origin. Because of the increasing number of reports, this clinical entity should be taken into consideration in the differential diagnosis of intracranial and intraspinal calcified lesions.

[Cervicobrachialgia - an update under special consideration of the surgical management]. / Zervikobrachialgie - ein Update unter besonderer Berücksichtigung der chirurgischen Therapie.

The classic cervicobrachialgia results acutely from cervical nerve root compression by disc herniation or subacutely by radicular compression after progressive spondylotic changes of the cervical spine. The clinical presentation includes local and radiating pain syndromes that can be accompanied by sensorimotor deficits. Besides the medical history and a targeted clinical examination, supplementary radiographic means should be undertaken to confirm diagnosis. If no urgent surgical indication exists, conservative therapy should be initiated. However, with varying results of conservative and surgical therapy, chronic impairment can occur.

Surgical treatment of unruptured intracranial aneurysms in a low-volume hospital--outcome and review of literature.

BACKGROUND: The aim of this study was to evaluate surgical outcome of unruptured intracranial aneurysms (UIAs) in a low-volume hospital and compare the results with the recent literature. METHODS: A retrospective review of all consecutive craniotomies for UIA from July 1999 through June 2009 was performed. Morbidity was defined as modified Rankin Scale (mRS) ≥ 3 and evaluated six weeks after surgery. Cognitive function was evaluated at rehabilitation-to-home discharge. A PubMed database search (2001-2011) seeking retrospective, single-center studies reporting on surgical outcome of UIAs was performed. RESULTS: There were 47 procedures performed in 42 patients to treat 50 UIAs (mean of 5 annual craniotomies). The mean age was 54.7 ± 12.1 years and mean aneurysm size was 7.6 ± 4.0mm. Favorable outcome (mRS 0-2) at six weeks after surgery was achieved in 45 of 47 procedures (95.7%). Aneurysm size ≥ 12 mm was statistically significant related to adverse outcome defined as mRS change ≥ 1 (71% vs. 29%; p = 0.018). Five patients (10.6%) with favorable neurological outcome (mRS 2) presented with cognitive impairment at rehabilitation-to-home discharge. There was no significant difference in overall morbidity and mortality comparing low- and high-volume hospitals (4.0% vs. 4.8%; p = 0.85). CONCLUSIONS: Low-volume hospitals may achieve good results for surgical treatment of UIAs. The results indicate that defining numeric operative volume thresholds is not feasible to guide centralization of aneurysm treatment.

[The lumbar disc herniation - management, clinical aspects and current recommendations]. / Lumbaler Bandscheibenvorfall - Management, klinische Aspekte und aktuelle Empfehlungen.

Lumbar disc herniation has a high prevalence and strong social-medical impact. Patients suffer from lower back pain that radiates from the spine. Loss of sensation or paresis adds to the clinical picture. The diagnosis should be confirmed by imaging in patients considered for surgery. High remission rates initially warrant conservative treatment (adequate analgesia and physiotherapy) in many patients. If this treatment does not lead to significant alleviation within 5-8 weeks, surgery should be performed to reduce the risk of chronic nerve affection. Posterior interlaminar fenestration is the intervention primarily conducted for this diagnosis. A relapse in the same region occurs in up to 10% of patients after months through years, which sometimes necessitates a reoperation if symptoms are pertinent.

[Cerebral arteriovenous malformations: clinical aspects and treatment possibilities]. / Zerebrale arteriovenöse Malformationen: Klinische Aspekte und Therapieoptionen.

Cerebral arteriovenous malformations (AVM) are vascular lesions that occur either congenitally or arise in early childhood. AVM are characterised by arteriovenous shunts through a nidus of coiled and tortuous vascular connections that connect feeding arteries to draining veins. Generally, AVM become evident through intracranial haemorrhage in patients aged 20-40 years. Especially, in the young adult presenting with epileptic seizures or focal neurological deficits AVM needs to be considered as an important differential diagnosis. Treatment modalities for the occlusion of symptomatic AVM include microneurosurgery, endovascular embolisation, or radiosurgery. These can be performed each on its own or in combination with the others. Incidentally diagnosed AVM require a thorough and individual consideration of treatment indications. This review deals with the current recommendations for the treatment of AVM in the adult patient.

[Intracerebral haemorrhage - when is a surgical treatment reasonable?]. / Intrazerebrale Blutung - wann ist eine chirurgische Behandlung sinnvoll?

Intracerebral haemorrhages (ICH) are responsible for 10-17% of all strokes and are associated with a high mortality and morbidity. More than 50% of the primary cases of ICH are associated with an underlying arterial hypertension and up to 30% with a cerebral amyloidosis. In supratentorial ICH, primary treatment generally should be conservative, as clinical studies could not show favourable outcomes after surgical haematoma evacuation. However, in patients with infratentorial haemorrhages and neurologic deterioration, early surgical evacuation should be considered. Modern therapeutic strategies and the focus of current and recent clinical research include early haemostasis, improvement of intensive care, and less invasive neurosurgical interventions, with the aim to reduce secondary brain damage. This review provides an overview of the clinical presentation of ICH and includes up-to-date recommendations concerning diagnostic and therapeutic options.

[Spinal tumors - part 1: extradural tumors. Epidemiology, clinical aspects and therapy]. / Spinale Tumoren - Teil 1: Extradurale Tumoren. Epidemiologie, klinische Aspekte und Therapie.

Spinal tumors are classified according to their location in extradural, intradural-extramedullary, and intradural-intramedullary tumors. The most frequent extradural tumors are metastases. Primary spinal tumors are rare and predominantly benign. Independent of their origin, spinal tumors manifest themselves with progressive local or radicular pain and neurological deficits. A preferably early diagnosis and subsequent therapy is important to improve the prognosis. The treatment of choice for most of these tumors is the complete surgical resection. In particular with the occurrence of neurological deficits a fast surgical intervention is indicated, since the prognosis depends on duration and severity of the preoperative existing deficits. Below, clinical presentation and relevant treatment options of spinal extradural tumors are discussed.

[Spinal tumors - part 2: intradural tumors. Epidemiology, clinical aspects and therapy]. / Spinale Tumoren - Teil 2: Intradurale Tumoren. Epidemiologie, klinische Aspekte und Therapie.

Intradural spinal tumors are classified in extra- and intramedullary tumors. The most frequent intradural-extramedullary tumors are meningiomas and neurinomas. Among the intradural-intramedullary tumors the most frequent ones are ependymomas and astrocytomas. Independent of their origin, spinal tumors usually manifest with progressive local or radicular pain and neurological deficits. The treatment of choice for most of these tumors is a complete surgical resection. In tumors with infiltrative growth into the intramedullary area, a marginal tumor tissue has to be left in situ in order to avoid additional neurological deficits. In particular if neurological deficits appear, a fast surgical intervention is indicated, since the prognosis depends on duration and severity of the preoperative existing deficits. Below, clinical presentation and relevant treatment options of spinal intradural tumors are discussed.

[Adult syringomyelia - a syndrome of different origins]. / Die Adulte Syringomyelie - ein Krankheitsbild mit Verschiedenen Ursachen.

Syringomyelia describes an intra-medullary cyst in the spinal cord. In the adult patient, the pathology mostly results from Chiari-I-malformation or from severe spinal trauma. The clinical picture varies broadly, but symptoms often include pain and progressive neurologic deficits. During the clinical course, muscular atrophy and loss of pain and temperature sensation may develop in the affected region. Today, magnet resonance imaging helps to detect syringomyelia at an early stage. The interdisciplinary therapeutic approach includes an adequate pain treatment and physiotherapy, in selected cases a surgical intervention by an experienced surgeon. If not treated surgically, most symptomatic patients experience progressive neurologic deficits that may lead to severe paragplegia and chronic neuropathic pain.

[An uncommon reason for facial hypoesthesia]. / Eine ungewöhnliche Ursache für faziale Hypästhesie.

A 58-year-old female admitted herself to the emergency department with progressive left-sided facial hypoesthesia. Magnetic resonance imaging revealed a 20 mm-sized aneurysm of the left vertebral artery leading to compression of the trigeminal nerve. An endovascular occlusion with a combined coiling and flow-diverter was performed. The left posterior inferior cerebellar artery (PICA) arised from the aneurysmal sac. Despite an extensive infarction of the left PICA-territory, the patient convalesced well and presented completely independent and without symptoms at the 4-week follow-up.

[Deep brain stimulation - options and limits]. / Tiefe Hirnstimulation - Möglichkeiten und Grenzen.

Deep brain stimulation (DBS) is meanwhile an established procedure. It has been employed for several neurological diseases with impressive therapeutic responses to some extent. Stimulation of the ventral intermediate nucleus of the thalamus can distinctively improve tremor associated with essential tremor or Parkinson disease. Similarly, stimulation of the subthalamic nucleus or the globus pallidus internus can substantially diminish bradykinesia, rigidity, and tremor. Additionally, by means of a reduced dopaminergic therapy, it can lead to an improvement of the L-Dopa induced dyskinesias in patients with Parkinson disease. In recent years, DBS has also been used for other neurological and psychiatric diseases. Yet, the exact mechanism of action on a neuronal level remains uncertain. Regardless of the underlying disease and the surgical electrode positioning, a meticulous patient selection and correct indication is of paramount importance for the therapeutic success.

[Does smoking correlate with low back pain and the outcome of spinal surgery?]. / Beeinflusst Rauchen Rückenschmerzen und spinale Operationsergebnisse?

BACKGROUND: For a long time, orthopaedic surgeons have suspected an influence of smoking on several musculoskeletal diseases. The aim of this review is to discuss the influence of smoking on low back pain (LBP) and the outcome of spinal surgery. LBP is a highly prevalent disease and plays an important economic role, as it is associated with high direct and indirect health-care costs. In order to be successful in prevention, risk factors for LBP must be identified. METHODS: A review of the literature (using PubMed with the search terms: smoking, low back pain and pathophysiology) was performed. Of the search results, 196 publications from peer-reviewed journals were analysed (including three randomised clinical trials, 134 clinical, 28 experimental articles and 31 reviews [including one Cochrane Database review and five systematic reviews]). Additionally, 11 official publications of the US Department of Health and Human Services, the International Agency for Research on Cancer (France) and the "Deutsches Krebsforschungszentrum" were used. RESULTS: While the evidence level for severe adverse effects of smoking on osteoporosis is good, many studies performed on LBP describe a statistical association, but are not useful to detect a causal link between smoking and lumbar disease. However, with plausible pathophysiological mechanisms and an overwhelming number of studies identifying a correlation it is suggested that smoking is likely to contribute to LBP and affects spinal surgery adversely. As for all diseases with multifactorial (including psychosocial) aetiology, it proves difficult to distract the confounding factors for analysis. CONCLUSION: A high number of studies performed to identify an association between smoking and LBP have not led to a final conclusion. But still, on the basis of the current knowledge, a negative contribution of smoking on LBP and spinal surgery seems probable.

[The intracranial meningioma - therapeutic possibilities and limitations]. / Das intrakranielle Meningeom - Therapeutische Möglichkeiten und Grenzen.

Meningiomas are common intracranial tumours that arise from arachnoidal cells. Clinically they often manifest by headache, focal or generalized seizures, or neurologic deficits as a result of brain compression. More than 90 percent of these mostly slow growing meningiomas are benign. In symptomatic patients a resection should be performed with the intention to cure or at least alleviate symptoms. In cases of subtotal resection an adjuvant radiotherapy should be deliberated. Stereotactic radiotherapy as initial treatment is an effective alternative for meningiomas, especially in patients not suitable for surgery due to various reasons. In patients that are refractory to treatment or with unresectable disease a hormonal- or chemotherapy can be considered.