[Metastatic Pituitary Disorders]. / Metastatické postizení hypofýzy.

BACKGROUND: Pituitary metastases are a rare complication of generalized cancer. Metastases to the pituitary gland occur in only 1% of patients operated on for sellar tumor. The most common presenting symptom in patients with pituitary metastases is diabetes insipidus, whereas this is rare in those with pituitary adenoma. MATERIAL AND METHODS: This publication presents the cases of two patients with pituitary metastases and a systematic review of the literature. English-language publications related to pituitary metastases and published from 1957 to 2016 were identified using the PubMed database. RESULTS: A total of 131 publications containing information about 259 patients (121 female and 138 male; mean age, 57.3 years) were identified. The most often metastasized breast carcinoma (24.6%) and lung carcinoma (23.8%), followed by thyroid carcinoma (11.3%), renal cell carcinoma (7.8%), hepatocellular carcinoma (4.3%), colorectal carcinoma (3.5%), and malignant melanoma (3.5%). The most frequent initial symptoms were manifestations of diabetes insipidus (39.6%), anterior pituitary deficiency (44.9%), perimeter disorders (51.6%), headache (37.6%), cranial nerve palsy (33.5%), and pseudoprolactinemia (16.7%). Radiotherapy (67.8%) and surgical treatment (63.9%) were the most frequently used treatment. CONCLUSION: The average survival time from the onset of metastatic disease was 11.8 months. Surgical therapy alone or in combination with radiation therapy does not prolong survival, but alleviates symptoms and improves quality of life.Key words: pituitary metastasis - diabetes insipidus - hypopituitarism - transsphenoidal surgery The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 13. 1. 2017Accepted: 4. 4. 2017.

[Autologous cranioplasty with a bone flap preserved subcutaneously in the mesogastrium]. / Autologní kranioplastika deponovanou kostní ploténkou v podkozí mezogastria.

INTRODUCTION: Cranioplasty with autologous bone flap is indicated in patients who have undergone decompressive craniectomy. Although it is an elective procedure, literature data indicate complication rates of up to 30%. The aim of this paper is to present our experience with cranioplasty with the patients own bone flap stored subcutaneously in the mesogastrium. METHODS: We retrospectively analyzed a set of 92 patients who had undergone cranioplasty after decompressive craniectomy using autologous graft preserved subcutaneously in the mesogastrium. The patients were clinically and radiologically examined before the surgery, and six weeks and one year after surgery. We evaluated the incidence of acute complications - wound hematoma, and late complications - infection and bone resorption. The postoperative cosmetic effect and patient discomfort from the stored bone flap also constituted an important aspect. RESULTS: The frequency of complications in our study group was 25%. Late complications were the most common, occurring with a frequency of 13%. These were mainly resorption of the bone flap (4.3%) and infectious complications (4.3%). Acute complications occurred with a frequency of 10.9% in our patient group. The most serious complication was cerebral edema of unknown origin leading to death of the patient. Unsatisfactory cosmetic effect as well as discomfort at the site where the flap was stored occurred in two cases. CONCLUSIONS: Cranioplasty is associated with a higher risk of complications in comparison with other elective procedures. Nevertheless, we regard cranioplasty with subcutaneously preserved bone flap as an inexpensive and suitable alternative to cryopreservation or alloplastic materials.Key words: cranioplasty complications of cranioplasty autologous cranioplasty decompressive craniectomy.

[A Patient with Primary Intraventricular Gliosarcoma and Long-term Survival - a Case Report]. / Pacientka s primárním intraventrikulárním gliosarkomem s dlouhodobým prezíváním - kazuistika.

BACKGROUND: Gliosarcoma is a rare, malignant CNS tumor with a very poor prognosis. Gliosarcoma is a variant of glioblastoma multiforme, which is characterized by the presence of both glial and mesenchymal components. The treatment strategy for gliosarcomas has not yet been determined clearly. CASE PRESENTATION: This case report presents a 23-year-old female patient who complained of increasing headaches, nausea and vomiting, and slight motor weakness in her left arm. An MRI scan of the brain showed a tumor filling the anterior part of the right lateral ventricle and extending into the right frontal lobe. Tumor extirpation was performed. Histology revealed gliosarcoma. Subsequently, the patient received concomitant chemoradiotherapy with temozolomide in the Stupp regimen. Following the fourth cycle of maintenance temozolomide chemotherapy, at eight months after diagnosis, an MRI scan detected progression of the tumor residue. The patient underwent another surgery and then received 10 cycles of second-line chemotherapy in the ICE (ifosfamide, carboplatin, and etoposide) regimen. She completed oncological therapy with minimal toxicity and follow-up MRI scans showed virtually no residual tumor. Another follow-up MRI scan, performed 28 months after diagnosis, demonstrated progression of the tumor residue again. A third tumor resection was performed 29 months after initial diagnosis. Histology again confirmed gliosarcoma. An early postoperative MRI scan showed subtotal resection with a tumor residue in eloquent areas and also suspected implantation metastasis in the spinal canal at the C2 level. From the neurological perspective, the patient was fully self-sufficient, and had only a very mild motor deficit in her left arm. Currently, at 31 months after initial diagnosis, the patient is in a stable condition and fully self-sufficient. CONCLUSION: Our case report shows that long-term survival can be achieved in a gliosarcoma patient exhibiting all the unfavorable features in clinical-pathological terms. The minimal recommended treatment is maximal resection followed by adjuvant radiotherapy. Our patient also underwent chemoradiotherapy with temozolomide in the Stupp regimen. Recurrence at eight months after diagnosis was managed by a repeat operation and high-dose combination chemotherapy, which kept the disease in remission for 20 months after the initial relapse. The lack of unequivocal rules for chemotherapy provides an opportunity to test less common treatment regimens.Key words: gliosarcoma - surgery - chemotherapy - radiotherapy - survivalThis study was supported in part by the grant No. NT13581-4/2012(86-91) of the Internal Grant Agency of the Czech Ministry of Health.The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 26. 3. 2016Accepted: 27. 4. 2016.

[Multimodal Therapy of Recurrent Malignant Schwannoma]. / Kombinovaná lécba recidivujícího maligního schwannomu.

BACKGROUND: Malignant peripheral nerve sheath tumor schwannoma (MPNST), also known as malignant schwannoma, is a very rare tumor accounting for only 2% of all sarcomas. The prognosis is relatively poor, with a 5-year survival rate of 46-69%. The treatment of MPNST has not been standardized yet. Mainstay treatment is radical resection. Oncological adjuvant or neoadjuvant treatment has equivocal indications with unclear effects. CASE: The case report presents a 55-year-old patient who showed resistance in the medial-ventral area of the left lower limb. An MRI scan showed a tumor adjacent to the femoral nerve. Tumor extirpation was performed. Histology revealed malignant schwannoma (MPNST) and the resection was assessed as R0. Postoperative whole-body PET/CT revealed no viable tumor tissue. The patient was regularly followed-up. On a follow-up MRI scan, performed 53 months after initial surgery, tumor recurrence was detected in the left thigh. Extirpation of the recurrent tumor was performed. Histology confirmed MPNST and the resection radicality was assessed as R2. Postoperative PET/CT revealed tumor residues. Therefore, 58 months after the initial surgery, another operation of the residual tumor was performed with R0 resection. Three applicators for interstitial brachytherapy were placed in the resection cavity. Following the operation, radiotherapy with an interstitial brachytherapy boost of 18 Gy followed by external fractionated radiotherapy of 50 Gy were administered. The latest MRI scan, performed 66 months after the diagnosis of MPNST, showed no tumor tissue. The patient had no neurological deficit. CONCLUSION: The mainstay of treatment for MPNST is radical en bloc resection. The use of subsequent oncological therapy depends on the radicality of the resection. In our case, because of the good radicality of the initial surgery, adjuvant oncological therapy was postponed. As part of recurrence management, we again attempted to achieve the most radical resection possible and then apply adjuvant radiotherapy. In MPNST, as in all soft tissue sarcomas, high doses are chosen because of potential radioresistance. Given the confined nature of the disease, we chose this locally intensified therapeutic strategy, which resulted in this case in disease remission. Due to the low incidence of MPNST, it is not possible to test the efficacies of individual oncologic therapeutic procedures in larger patient cohorts.Key words: malignant schwannoma - soft tissue sarcoma - multimodal therapyThe authors declare they have no potential confl icts of interest concerning drugs, products, or services used in the study.The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 13. 3. 2016Accepted: 25. 4. 2016.

[Influence of Cervical Spondylotic Spinal Cord Compression on Cerebral Cortical Adaptation. Radiological Study]. / Vliv cervikální spondylogenní mísní komprese na korové funkce mozku. Radiologická studie.

PURPOSE OF THE STUDY: The aim of the study was to measure the sensorimotor brain adaptation activity, shown on functional magnetic resonance images (fMRI), in relation to the degree and extent of spinal cord compression or cervical spondylotic myelopathy (CSM) detected by cervical spine MRI. MATERIAL AND METHODS: Twenty-one patients (average age, 57 years; 9 men and 12 women) with anterior cervical cord compression detected on cervical MRI scans were included. On the images, the degree of spinal canal stenosis, the spinal cord compression based on the antero-posterior diameter of the spinal canal and on transverse areas of the cervical spinal cord and cervical spinal canal, and changes in spinal cord signal intensity were identified. Clinical examination included neurological status, Japanese Orthopaedic Association (JOA) score, Neck Disability Index (NDI) and pain intensity assessment using the Visual Analogue Scale (VAS). Electrophysiological tests involving motor evoked and sensory evoked potential (MEP and SEP) recording were conducted and, using fMRI, brain activity during movement of both arms was measured. Based on the transverse spinal cord area of above or below 70 mm2, the patients were placed into two subgroups. According to changes in spinal cord signal intensity, the patients were included into three subgroups with normal findings, incipient myelopathy and advanced myelopathy, respectively. Surgery was carried out from the anterior approach and involved cervical disc replacement. All examinations were performed again at 6 months after surgery. Pre- and post-operative results were compared within each set of subgroups and statistically evaluated. RESULTS: The average pre-operative values were found to increase post-operatively as follows: from 6.4 mm to 8.9 mm (by 39%) for the antero-posterior diameter of the spinal canal; from 129.3 mm2 to 162.8 mm2 (by 26%) for the transverse area of the spinal canal; from 72.6 mm2 to 87.4 mm2 (by 20%) for the transverse spinal cord area; and from 16.3 to 17.4 for the JOA score. The average NDI decreased from 37.9 to 23.7 and the average VAS fell from 6.4 to 1.5. All patients with the change of spinal cord signal that indicated advanced myelopathy also had relevant pathological findings on MEP/SEP examination and this was statistically significant. There was no significant difference in fMRI scans between the two subgroups established on the basis of transverse spinal cord area measurements. In the patients grouped by a change in spinal cord signals, the pre-operative fMRI showed a significantly higher brain activation volume in the subgroup with advanced myelopathy, as compared with the two other subgroups. Surgery resulted in a moderate reduction of the volume of active brain tissue in all three groups. In the patients with advanced myelopathy evaluated in relation to local changes in brain activation, surgery led to a significant decrease in activation volumes in the ipsilateral primary motor cortex and cerebellar hemisphere. There was also a significant increase in activation of the contralateral supplementary motor cortex. DISCUSSION: It is evident that the brain responds to spinal cord damage by increased activity, but with a certain delay. A slightly altered spinal cord signal intensity, such as in incipient myelopathy, apparently does not result in brain activation. On the other hand, significant changes in signal intensity in advanced myelopathy are related to deterioration of spinal cord function, as shown by MEP and SEP examination results, and an increase in both the volume and intensity of cortical motor activation as a compensation mechanism for myelopathy. CONCLUSIONS Hyperintense spinal cord signals on T2-weighted images correlated with the pathological spinal cord function detected by electrophysiological test in all patients. The transverse spinal cord area (around 70 mm2) showed no significant correlation with either sensory and motor brain adaptations or the results of SEP and MEP testing; therefore, as a criterion for indication to surgery it is of no value. The patients with advanced myelopathy, as detected by spinal cord MRI, had a significantly higher pre-operative cortical motor activation on fMRI than patients with normal findings or those with incipient myelopathy. In addition, the patterns of cortical motor activation altered significantly at 6 months after spinal cord decompression, which was shown by an increase or decrease in activation of the relevant motor cortex areas.

[Use of artifiial bone in lateral interbody fusion of the lumbar spine: a prospective radiographic study]. / Pouzití umelé kostní náhrady pri laterální mezitelové fúzi na bederní páteri: prospektivní radiologická studie.

PURPOSE OF THE STUDY: The aim of the study was to evaluate the extent of fusion using synthetic ß-tricalcium phosphate as a bone substitute in extreme lateral interbody fusion (XLIF). MATERIAL AND METHODS: In this prospective study, patients undergoing XLIF with an Oracle cage filed with the artifiial bone ChronOs Strip (Synthes, USA) were evaluated. The group consisted of 61 patients, 33 women and 28 men, with an average age of 50.9 years (range, 21 to 73 years). A total of 64 segments were operated on. Stand-alone interbody fusion was performed in 14 segments, lateral plate fiation in 19, transpedicular (TP) fiation before XLIF was carried out in 14 and TP fiation after XLIF in 17 segments. At one-year follow-up, dynamic X-rays to exclude instability, and CT images were obtained in order to evaluate the extent of bone fusion outside the implant (complete fusion, partial fusion, no fusion) and inside it (% of the bone fusion surface area). In addition, bone mineral density following fusion mass bone quality (expressed in Hounsfild units [HU]) was assessed inside the implant at the site of ChronOs Strip placement, using a region of interest (ROI) analysis. For the evaluation of fusion bone quality inside the implant on CT scans with HU qualifiation, the authors propose the following scale: 1. no fusion (0-99 HU) 2. Uncertain fusion (100-190 HU) 3. Probable fusion (200-299 HU) 4. Reliable fusion (300 and more HU) All results were statistically evaluated in relation to the gender, age, treated segment, surgical diagnosis, method of fiation, implant height and intervertebral space reduction at one-year follow-up. RESULTS: Fusion outside the implant was complete in 18 segments (28%) and partial in 27 (42%); in 19 segments (30%) it was not detected. The bone fusion surface area inside the implant was 54.5% (0-100%) on the average. It was related to age and implant height; the surface area increased with increasing age and with increasing implant height. Solid bone fusion inside the implant, as assessed on CT images using HU, was reliable in 36 segments (56%), probable in 11 (17%), uncertain in 10 (16%) and was not detected in seven segments (11%). A signifiant relationship was found between the quality of bone fusion and the type of fiation. Of the segments treated by stand-alone XLIF, 29% showed no fusion while the segments managed by lateral plate fiation had 32% of them with probable fusion. Correlations were also found with the height of an implant (the higher the implant, the more reliable its fusion), with age (the higher age, the higher bone density) and with the spinal level (the lower level, the lower bone density). In 45 (70%) segments, bone mineral density inside the implant was higher than the density of surrounding spongious bone. The average density inside the implant was 333.7 HU (14-1075) and that of the surrounding bone was 244.6 HU (66-500). The intervertebral space was reduced by an average of 1.1 mm (0-6.2). All treated segments were found stable on dynamic X-rays. DISCUSSION: The use of a tricortical bone graft collected from the iliac crest is associated with pain at the harvest donor site in 2.8% to 39% of the cases, and this has been an impetus for many surgeons to use bone substitutes. In terms of the final outcome, i.e., solid bone fusion, the difference between the resorption rates of allogenous graft/artificial bone and ingrowth of autologous bone (from vertebral bodies) plays the most decisive role. CONCLUSIONS: The change of (3-tricalcium phosphate to bone tissue is not always reliable and this can largely be expected when the resorption rate of ChronOs strip is low, i.e., at higher patient age and with a higher height of the implant.The authors recommend increasing the probability of solid fusion in XLIF by using lateral plate fixation.The method of assessing bone fusion by measuring bone density on CT scans proved to be useful because of its objectivity, and it can replace the current assessments based only on subjective judgement.

[Surgery for degenerative spondylolisthesis of the lumbar spine using intra-articular fusion. A prospective study]. / Operace degenerativní spondylolistézy bederní pátere metodou intraartikulární fúze: prospektivní studie.

PURPOSE OF THE STUDY: The aim of the study is to present our surgical method of treating degenerative spondylolisthesis, which includes radical bilateral laminectomy to relieve compression on the spinal cord, transpedicular fixation of the segment and arthrodesis by bilateral intra-articular fusion. MATERIAL AND METHODS: This surgery was indicated in patients with grade I or grade II of degenerative sponylolisthesis with a 4-mm or more slippage. Our prospectively studied group consisted of 46 patients (17 men, 29 women; average age, 64.2 years; range, 39-84 years). Before surgery and at 1 year after the procedure, the intensity of axial pain and that of radicular pain were each assessed using the visual Analogue Scale (VAS). Difficulty in performing daily living activities was measured by the Oswestry Disability Index (ODI). The surgical procedure included laminectomy, partial medial facetectomy, foraminotomy to relieve pressure on the spinal nerve roots and transpedicular fixation to provide stability. Using a cutter, cartilage was separated off the cortical bone and, in order to facilitate fusion, bone cavities thus produced were filed with corticospongious grafts harvested from the removed vertebral arch with Kerrison forceps. At 1-year follow-up, dynamic X-ray was used to evaluate spine alignment and, on a CT scan, the degree of intra-articular fusion was assessed. Fusion was achieved when bone density measurement showed more than 350 Hounsfield Units (HU). For the measurements, the authors used their own modified method by means of a Region of Interest (ROI) analysis. The clinical and radiographic results were statistically evaluated. RESULTS: At 1 year after surgery, lumbar flexion-extension bending X-ray films revealed stability of the treated segments in all patients (100%). CT examination showed bone density higher than 350 HU at both joints, i.e., complete bone fusion, also in all 46 patients. The mean post-operative ODI score was significantly lower than its mean pre-operative value (23.6 vs 55.4), which was improvement by 57.4%. The differences in pre- and post-operative VAS scores were also statistically significant. The mean VAS score for low back pain decreased from 7.61 to 1.74, i.e., improvement by 77.1%, and the mean vAS score for radicular pain dropped from 6.98 to 1.24, i.e., improvement by 82.2%. Assessed by Odom's outcome criteria, the results were excellent in 26 patients and very good in 20 patients, and they were not related to age, gender or the spinal level treated. Any complications associated with the operative procedure or wound healing and requiring repeated surgical treatment were not recorded. DISCUSSION: The surgical technique described here has advantages over other methods in reliable achieving nerve decompression, joint fusion and spinal stability at low costs and short operative time. In addition, it avoids the necessity of harvesting bone from the iliac crest. CONCLUSIONS: At 1-year follow-up all patients showed better health conditions, with improvement in average scores for the ODI by 57%, for low back pain by 77% and for radicular and claudication pain by 82%. The technique of intra-articular fusion for treatment of degenerative spondylolisthesis resulted in solid bone fusion and spinal stability in all patients.

[Effects of spinal cord decompression in patients with cervical spondylotic myelopathy oncortical brain activations]. / Efekt dekomprese krcní míchy pri spondylogenní myelopatii na korové funkce mozku.

INTRODUCTION: The aim of this project was to compare and evaluate cortical sensorimotor adaptations as measured by brain fMRI (functional magnetic resonance imaging) in patients before and after surgery for cervical spondylotic myelopathy (CSM), i.e., after spinal cord decompression. MATERIAL AND METHODS: Study inclusion required evidence of CSM on MRI of the cervical spine, anterior compression of the spinal cord by osteophytes, or disc herniation. We measured the antero-posterior diameter of the spinal canal stenosis before and 3 months after surgery. Surgery was performed at one or two levels from the anterior approach with implantation of radiolucent spacers, without plate fixation. Each participant underwent two fMRI brain examinations, the first one preoperatively and the second one 6 months following surgery. Subjects performed acoustically paced repetitive wrist flexion and extension of each upper extremity according to block design. MRI data were acquired using 1.5 Tesla scanners. Statistical analysis was carried out using the general linear model implemented in FEAT 6.00 (FMRI Expert Analysis Tool), part of the FSL 5.0 package (FMRIB Software Library). The group differences were evaluated using paired t-test and the resulting statistical maps evaluated as Z-score (standardised value of the t-test) were thresholded at a corrected significance level of p <0.05. The study group consisted of 7 patients including 5 female and 2 male patients, with the average age of 55.7 years. Patients with cervical spondylogenous radiculopathy were evaluated as a control group. RESULTS: The analysis of mean group effects in brain fMRI during flexion and extension of both wrists revealed significant activation in dorsal primary motor cortex contralaterally to the active extremity and in adjacent secondary motor and sensory areas, bilaterally in supplementary motor areas, the anterior cingulum, primary auditory cortex, in the region of the basal ganglia, thalamus and cerebellum. After surgery, the cortical activations and maximum Z-scores decreased in most areas. Analysis of differences between sessions before and after surgery showed a statistically significant activation decrease during movement of both extremities in the right parietal operculum and the posterior temporal lobe. During left wrist movement, there was additional activation decrease in the right superior parietal lobe, the supramarginal gyrus, insular cortex, and the central operculum. In contrast, an activation decrease was detected in the left middle temporal gyrus during right wrist movement. CONCLUSION: An average difference of anteroposterior cervical spinal canal distance before and after surgery of CSM was 2.67 millimetres, representing a 40% increase; the cross-sectional area of the spinal canal increased by 37% and that of the spinal cord by 36%. Functional MRI of the brain revealed significant activation especially in primary and secondary motor cortex and sensory areas in patients with CSM. After surgical decompression of the spinal cord, cortical activations and maximum Z-score decreased in the majority of areas. We proved decreased cortical activation on functional MRI of the brain after surgery in patients with CSM (evaluated according to MRI of cervical spine), even at an initial stage of the disease.

[Percutaneous interspinous dynamic stabilization (in-space) in patients with degenerative disease of the lumbosacral spine - a prospective study]. / Perkutánní interspinózní dynamická stabilizace (In-Space) u nemocných s degenerativním onemocnením lumbosakrální pátere - prospektivní studie.

INTRODUCTION: Interspinous spacers are supposed to reduce the segmental extension with a decrease in the expansion of yellow ligaments into the spinal canal, thus avoiding the dynamic narrowing of the spinal canal and compression of nerve roots. The aim of this study was to evaluate clinical outcomes and post-operative complications during one year in patients mostly having suffered from spinal stenosis and treated by In-Space interspinous spacer (Synthes, USA). MATERIAL AND METHODS: A total of 25 patients aged between 25 and 73 (average age 52.6) years, including 18 males and 7 females, with degenerative disease of the lumbosacral spine were indicated for surgery and prospectively followed up. The patients were operated on under general anaesthesia in the prone position, using a minimally invasive lateral percutaneous approach, under fluoroscopic control. The ODI and VAS values as well as X- rays (Range Of Motion and Sagittal angle of the operated segment) 6 and 12 months after the surgery were compared to each other and to those before surgery. The results were statistically analyzed. RESULTS: The average ODI of the group was 47.2% before surgery and 17.48% 6 months (22.76% 12 months) after surgery, showing a statistically significant improvement by 63% (52% after 12 months). The average VAS of the group was 6.64 points before surgery and 2.96 points 6 months (2.8 points 12 months) after surgery, which showed a statistically significant improvement by 55.4% after 6 months (57.8% after 12 months) when compared to preoperative status. After surgery the lordotic sagittal angle remained in all cases; one year after surgery the angle increased due to the slight sinking of some implants. The extent of segmental motion was minimally changed (6.1° 6 months and 7.24° 12 months after surgery). No serious complications occurred. The effect of interspinous implants proved insufficient in two cases (one year and two years after surgery) and conversion to arthrodesis or decompression was performed. CONCLUSIONS: 1. Percutaneous, minimally invasive insertion of an In-Space interspinous spacer is an effective and safe method of dynamic stabilization not accompanied by any serious complications. 2. ODI improved by 63% 6 months after surgery with a decrease in this effect 12 months after surgery. VAS for axial and radicular pain, as reported by patients, improved on average by 55.4% 6 months and by 57.8% 12 months after surgery. 3. In all cases, the lordotic sagittal angle remained after surgery and the extent of segmental motion from flexion to extension was minimally changed.

[The DIAM spinal stabilisation system to treat degenerative disease of the lumbosacral spine]. / Implantace interspinózní rozperky DIAM u pacientu s degenerativním onemocnením lumbosakrální pátere.

PURPOSE OF THE STUDY: Each dynamic stabilisation should preserve motion at the operated segment as well as reduce a load on the disc and intervertebral joints. One of the methods to achieve this is the implantation of interspinous spacers between lumbar spinous processes. In this study, the patients treated with the DIAM interspinous spacer (Medtronic, USA) were prospective- ly followed up with the aim to evaluate clinical outcomes and post-operative complications. MATERIAL: Patients with a degenerative disease of the lumbosacral spine were indicated for the operation. They suffered from axial pain with signs of nerve root involvement due to disc hernia, foraminal stenosis or disc herniation recurrence A total of 68 patients aged 23 to 75 (average age, 50.01) years, including 39 men (average age, 50.44) and 29 women (average age, 49.45), were followed up for 1 to 3 years and evaluated. METHODS: All patients underwent a standard pre-operative clinical and neurological examination. Each patient assessed pain intensity using a Visual Analogue Scale (VAS) and, with an Oswestry Disability Index (ODI) questionnaire, evaluated their functional state. In the case of disc hernia or disc herniation recurrence, a sequester was removed; for foraminal stenosis, foraminotomy and partial medial facetectomy was performed. After this decompression of nerve structures, a spacer was implanted. Follow-up included clinical and neurological examination at 6 weeks, 6 months and 1 - 3 years post-operative- ly. At 6 months and between 1 and 3 years after surgery, pain intensity and functional outcome using VAS and ODI assessments were measured by the patients, and antero-posterior and lateral skiagrams of the lumbosacral spine were made. The X-ray examination was made to reveal a potential implant dislocation. The VAS and ODI values at 1-3 post-operative years were compared with those before surgery and the results were statistically analysed. The surgeon evaluated the outcomes at 1-3 years of follow-up according to the Odom criteria. RESULTS: The average ODI of the group was 60.44 % before and 21.85 % after surgery, which showed an improvement by 63.85%. The average VAS was 7.18 points before and 2.10 points after surgery, showing an improvement by 70.75 %. A comparison of the pre- and post-operative results showed, in the average ODI differences of 38.24 % and 39.44 % in women and men, respectively; and in the average VAS value, 5.00 in women and 5.19 in men. The results evaluated according to indication for surgery were as follows: in patients with disc hernia, the difference in ODI was 39.62 % on average, and in VAS it was 5.42 points on average. In patients with disc herniation recurrence, the differences between pre- and post-operative average values were 41.50 % for ODI and 5.00 points for VAS. In patients treated for foraminal stenosis, these differences were 39.79 % for ODI and 5.18 points for VAS. The results for the level treated showed that at L5/S1 the average difference for ODI was 46.75 % and 4.50 points for VAS ; at L4/5 it was 35.52 % for ODI and 5.12 for VAS; at L3/4 it was 48.00 % for ODI and 5.78 for VAS; and at L2/3 it was 39.00 % for ODI and 4.50 for VAS.The results related to the method of nerve root decompression included the average differences of 40.00 % in ODI and 5.17 in VAS for removal of a disc sequester; and average differences of 32.89 % in ODI and 4.78 in VAS for foraminotomy and partial medial facetectomy. The results evaluated for the duration of pre-operative complaints were as follows: surgery by 3 months, average ODI, 44, 53 % and average VAS, 5.25; surgery between 3 and 6 months, average ODI, 37.65 % and average VAS, 4.71; and surgery after 6 months, average ODI, 35.60 % and average VAS, 5.28. The Odom criteria showed results as excellent in 41 %, good in 51.5 % and fair in 7.5 % of the patients. No poor result was recorded. There were no early complications such as haematoma, wound seroma or deep subfascial infection, and no implant dis- location. One patient had to undergo repeat surgery for subcutaneous infection without affecting the implant. Until the end of the study, no signs of herniation recurrence at the segment stabilised with a Diam interspinous spacer had been found. DISCUSSION: The fact that none of the patients in this study required revision surgery or had a recurrence of disc herniation provides evidence for the effectiveness of the DIAM interspinous spacer.This also suggests that the implant protects the whole operated spinal segment, i.e., both intervertebral joints and discs, from being overloaded. Lesser mechanical stress applied to intervertebral facets may slow down degenerative processes and reduce their signs. CONCLUSIONS: The implantation of a DIAM interspinous spacer is a less invasive and safe method of dynamic stabilisation of the spi- ne without intra- or post-operative complications that is well tolerated by the patient. At 3-year follow-up the patients reported improvement in their functional state, as measured with an ODI, by 64 % on the average. Their axial and nerve root pain was reduced by 71 % on the average. All patients showed improved clinical conditions and the outcomes were evaluated as excellent in 41 %, good in 51 % and fair in 7.5 % of the patients. The results of implantation were not significantly related to age, gender, operative indications, operated lumbosacral level, method of nerve root decompression or duration of pre-operative problems. No patient treated by the DIAM spacer had any recurrence of disc herniation.

[Contribution of MRI to the thoracolumbar spine injuries diagnostics and therapy]. / Phínos magnetické rezonance pro diagnostiku a lécbu poranení torakolumbální pátere.

AIM: The aim of this study was to assess correlation between the degree of severity of the intervertebral disc injury and the vertebral enoplate injury, evaluated based on MRI, and the resulting final clinical condition and radiological findings. MATERIAL AND METHODOLOGY: The authors performed a prospective analysis of patients with thoracolumbar fractures type A1 or A3, without injuries to the nervous system. The study group included 73 subjects (the mean age was 45.52 years), 44 males and 29 females. The type A1 fracture group including 31 patients received conservative treatment and the type A3 fracture group including 42 subjects underwent surgery with posterior transpedicular (TP) fixation. After their injury, the patients were examined using plain x-rays, CT and MRI. At month 18 of their follow up, a control MRI examination was performed to assess spinal kyphotization, the spinal body height decrease and the clinical outcomes. RESULTS: The data underwent statistical evaluation. The conservative treatment group showed no statistically significant correlation between the severity of the intervertebral disc and vertebral enoplate trauma and the resulting final clinical outcome or radiological findings, however, the conservative treatment of the type A1 fractures failed in 9.3% of the subjects. This was due to the disc trauma and its consecutive replacement resulted in improvement of the clinical condition. Posterior TP fixation in the type A3 fractures did not prevent statistically significant higher rates of kyphotization and reduced weight- bearing tolerance in patients with more severe disc and vertebral enoplate traumas (grade 3 or 4), compared to patients with less severe traumas (grade 2). CONCLUSION: Posttraumatic assessment of the disc and vertebral enoplate trauma severity using MRI is of significance for predicting the fracture healing prognosis, as well as the final clinical outcome of the procedure.

[Cervical disc arthroplasty (Prodisc-C): analysis of 3 to 4- year follow up results]. / Artroplastika krcní ploténky (Prodisc-C): analýza výsledku po 3-4 letech sledování.

AIM: The aim of this study was to assess the heterotopic ossification rate (HO), the range of motion of the operated, as well as the adjacent segments and the clinical condition of patients following cervical arthroplasty over a medium-term period. METHODS: The entrance criteria for cervical arthroplasty (Prodisc-C, Synthes, USA) included: clinical symptoms of degenerative disorders of the cervical spine-axial and radicular pain or radicular compromise and their corresponding signs on MRI-soft disc hernia or spondylosis. The prospective study included 16 patients of 30-63 years of age (mean age 47.44) and the follow up duration was from 3 years and 3 months up to 4 years (mean duration 44 months). The following parameters were assessed prior to the procedure and 3-4 years after the procedure: clinical condition (NDI), axial pain and radicular pain scores (VAS) and x-ray findings. Statistical tests were used to assess the outcomes. RESULTS: 3-4 years after the procedure, significant improvements in NDI by 48.13%, in cervical pain VAS by 65.75% and in radicular pain VAS by 67.31%, were demonstrated. All the above results were statistically significant. Arthroplasty improved sagittal balance of the cervical spine and the resulting lordosis of the operated segment was more pronounced. HO was detected in 56.25% of the operated segments and resulted in a complete loss of the arthroplasty mobility in 18.75% of the segments. No statistical significant differencies in rates of NDI, axial VAS and radicular VAS changes were found between patients with HO grade III and IV and patients with HO grade 0-II. No cases of the implant dislocation, subsidence or non-healing were observed, no subjects required surgical revisioning of the arthroplasty and no cases of "adjacent segment diseases" were recorded. DISCUSSION: based on the current literature data, complete disc replacement results in clinical outcomes, which are similar to those in patients with segment fusion. However, statistically significant reduction in rates of surgical revisions, reoperations and additional fixations was observed in subjects with arthroplasty. HO and spontaneous arthroplasty fusion is a new phenomenon, which may have a negative impact on the potentially saving effect of the arthroplasty on its adjacent segments. CONCLUSION: 39-48 months following the Prodisc-C implantation, the below findings were demonstrated: 1. Statistically significant improvement in NDI by 48.13%, improvement in cervical pain VAS by 65.75% and radicular pain VAS improvement by 67.31%. 2. Arthroplasty resulted in improved sagittal balance of the cervical spine and the resulting lordosis of the operated segment was more pronounced. 3. HO was detected in 56.25% of the operated segments and resulted in a complete loss of the arthroplasty mobility in 18.75% of the segments. 4. No cases of the implant dislocation, subsidence or non-healing were observed, no subjects required surgical revisioning. 5. No cases of "adjacent segment diseases" were recorded.

[Anterior osteosynthesis of odontoid fractures]. / Uspesnost prední osteosyntézy fraktury dens axis.

PURPOSE OF THE STUDY The conservative treatment of an odontoid fracture with immobilization in a halo-vest or collar often results in pseudoarthrosis. Therefore, surgical treatment is preferred, and the Magerl-Böhler anterior osteosynthesis of the C2 dens is one of the options for achieving good bony union. The aim of this study was to show that the success of reducing an odontoid fracture is related to the direction of fracture lines and that of displacement, and that anterior osteosynthesis of the C2 dens provides sufficient stability when fixed either with one or two screws. MATERIAL Patients treated for odontoid fracture at the Department of Neurosurgery, Teaching Hospital of the Faculty of Medicine, Palacky University in Olomouc, were followed up and prospectively evaluated. From February 1994 to October 2006, 50 patients between 17 and 98 years of age (average age, 51.16 years) underwent surgery by the Magerl-Böhler method. Of them, 40 were men (average age, 46.0 years) and 10 were women (average age, 71.8 years). The minimum follow-up period was 1 year. METHODS In each patient, X-ray examination of the upper cervical spine in antero-posterior and lateral projections was done and a CT scan of the C2 vertebra was obtained. The radiographs were evaluated for location of the fracture, direction of the fracture line and direction of dens displacement. The fracture was then categorized according to the conventional classifications of Anderson- D'Alonzo (1974), Roy-Camille (1973) and White-Panjabi (1978). The patients with type II and some with type III fractures (shallow type) were indicated for surgery, regardless of fracture line direction and the direction and extent of displacement. Patients suspected of spinal cord injury were immobilized and the fracture was reduced by skull traction as soon as possible after injury. In patients without neurological deficit the fracture was reduced under general anaesthesia before surgery carried out by the Magerl-Böhler method from the anterior approach. The extent of antero-posterior displacement of the odontoid fracture was measured on lateral X-ray images at the first week after surgery and then at complete bony union. The results were statistically evaluated. RESULTS An anatomical position of the dens after reduction was achieved in 18 patients (38 %). In the remaining 32 patients, reduction was not complete but sufficient to permit screw insertion. Fractures with an anterior oblique fracture line were more difficult to reduce than fractures with a posterior oblique or a transverse fracture line. The average displacement values following reduction of the fractures were as follows: anterior displacement of 3.88 mm; posterior displacement of 1.86 mm; and anterior or posterior displacement of 1.08 mm. The differences were statistically significant. A recurrent displacement during bone healing occurred in 13 patients (26 %). It affected type A fracture in five of 17 patients (29.4 %), type B fracture in seven of 21 patients (33.3 %) and type C fracture in one patient out of 12 (8.3 %). The average extent of displacement was 1.53 mm in type A, 1.20 mm in type B, and 0.08 mm in type C fractures. The average displacement for the whole group was 1.04 mm. This implies that recurrent displacement of the dens was more frequent in fractures with an anterior oblique fracture line than in those with either posterior oblique or transverse fracture line, and this was statistically significant. Of the 43 patients with single-screw fixation, 12 (28 %) experienced recurrent displacement during healing, and of the seven patients with two screws one patient had displacement (14 %). Although the extent of displacement was higher in one-screw than in two-screw fixation (average, 1.17 mm and 0.29 mm, respectively), the difference was not statistically significant. In patients under 70 years of age, 21.6 % and, in patients over 70 years of age, 41.7 % of the fractures had recurrent displacement (average, 0.78 mm and 1.83 mm, respectively). This was not statistically significant. Bony union was achieved in all treated patients. DISCUSSION The success of reduction in displaced odontoid fractures depends on time between injury and treatment and, as reported in the literature, is more difficult after two weeks of injury. Anatomical reduction has been achieved in 65 % of displaced fractures regardless of the extent of displacement (5 mm or more). Fracture displacement after osteosynthesis of the dens with a single screw has been described in one of 17 patients (6 %), and union has been achieved in all cases. In our group recurrent displacement was found in 13 out of 50 patients (26 %). Exact data on the extent of recurrent odontoid displacement after anterior osteosynthesis is not available. It has been shown by biomechanical studies that one- or two- screw fixation provides comparable stability that, however, reaches only 50 % strength of an undamaged dens. CONCLUSION The anterior osteosynthesis of odontoid fractures was successful even in the patients in whom the fracture could not be sufficiently reduced. Union was achieved in all cases even though some fractures became displaced during bone healing and osteosynthesis therefore was not stable. Displacement and more difficult reduction were recorded more frequently in type A than in type B and C fractures.

[Anterior cervicothoracic junction surgery with partial sternotomy using an operative microscope]. / Prední prístup k cervikotorakálnímu prechodu cástecnou sternotomií s pouzitím operacního mikroskopu.

The anterior cervical approach with partial sternotomy allows exposure of the lower cervical and upper thoracic spine. The use of a operative microscope provides a better view of the spine and safer and more radical performance while the surgical approach remains minimal. The authors describe this surgical procedure and present the illustrative histories of three patients with tumors between the first and the third thoracic vertebra. A good knowledge of upper mediastinum anatomy and magnetic resonance examination are the basic prerequisite for a successful operation without complications. On approach from the right side, the right recurrent laryngeal nerve should be protected, on approach from the left side of the esophagus, the thoracic duct should be identified and protected. The procedure is well tolerated by patients. For this surgery, co-operation of the spinal surgeon with thoracic or cardiovascular surgeons is recommended. Key words: cervicothoracic junction, tumors, anterior cervical approach, sternotomy, operative microscope.

Glioblastoma multiforme in patients with history of extracranial cancer: Case series.

OBJECTIVES: Significant progress in treatment strategies improves the expectations of patients with extracranial cancers. Metastases are the primary consideration in patients with cancer history. In the case of neurologic disorders, the patient should undergo brain MRI. A rationale is presented for surgery, whole-brain or stereotactic radiotherapy, or chemotherapy. Recently, we have encountered misdiagnosed primary malignant brain tumours in patients with oncologic history who had been admitted for surgery for brain metastases. The aim of our study is to evaluate the incidence of concurrent cancers, to assess the relationship between previous cancer staging and primary brain tumour evaluation as well as to determine treatment efficiency. METHODS: From January 2007 to December 2011, we prospectively followed up patients with concurrent history of both extracranial cancer and subsequent glioblastoma multiforme. Information was collected on the clinical condition, imaging, history of extracranial cancer, previous and present surgical and oncologic procedures, and GBM histologic, cytogenetic, and molecular genetic investigations. RESULTS: Five patients were recruited: three females and two males. The average patient age at the time of GBM diagnosis was 65.6 years. Three patients had a history of breast carcinoma, one of renal carcinoma and one of colorectal carcinoma. Following the diagnosis of carcinoma, three patients received chemotherapy and radiotherapy, one patient had radiotherapy alone, and one had no adjuvant therapy. In all the cases, surgery revealed primary GBM, with a standard occurrence of genetic abnormalities (Table 1). The average time from the diagnosis of extracranial cancer to that of GBM was 4 years. Four patients underwent chemoradiotherapy and one had palliative radiotherapy. Two patients completed oncotherapy and their OS was 27 months and 19 months, respectively. One patient had post-surgical progression of hemiparesis. One patient had pulmonary embolism during oncotherapy and one had paraplegia caused by a pathological fracture of vertebras T5 due to breast carcinoma metastases. The OS was 11.8 months (range 3-27 months). All the patients succumbed to GBM progression.

[Combined approach to the treatment of severe aortic stenosis and to three coronary vessel diseases in patients with brain meningioma and severe stenosis of internal carotid artery]. / Kombinovaný prístup pri resení tezké aortální stenózy a onemocnení tri koronárních tepen u nemocného s mozkovým meningeomem a významnou stenózou pravé vnitrní krkavice.

The authors present a case report of a 76-year-old man with a simultaneous finding of severe aortic stenosis, three coronary vessel diseases, severe stenosis of internal carotid artery and brain meningioma. The patient was scheduled for carotid endarterectomy 2 months prior the aortic valve replacement and coronary artery bypass grafting. Brain meningioma was removed 3 months after the cardiac procedure. The authors present a successful interdisciplinary co-operation in the treatment strategy.

[Computed tomography in the diagnosis of recurrent herniated disks following prior lumbar intervertebral disk operations]. / Die Computertomographie in der Diagnostik von Diskushernienrezidiven nach vorangegangener lumbaler Bandscheibenoperation.

20 patients with recurrent symptoms following operations for disc prolapse and resistant to treatment were studied by CT, using plain and enhanced images. The results have been analysed. In 10 patients a recurrence of disc prolapse was diagnosed, and this was confirmed surgically in 8 cases. In 2 patients there was epidural scarring. The findings indicate that differential diagnosis between scarring and recurring prolapse can be accurately made by this technique.

[Penetration of antibiotics into the intervertebral disk]. / Penetrace antibiotika do intervertebrálního disku.

The role of antibiotics in the treatment and prevention of postoperative spondylodiscitis is still controversial. In a group of 15 patients operated on account of lumbar discopathy, the authors investigated the penetration of antibiotics into the intervertebral disc, in correlation to serum levels, when antibiotics were administered during operation. Despite high serum levels rolitetracycline was not detected in extirpated material of the disc, gentamycin reached 2-6% serum levels. The authors give an account of views on the role of antibiotics in the prophylaxis of postoperative spondylodiscitis and recommend their administration in particular in risk groups. They recommend antibiotics in case of early diagnosis of postoperative spondylodiscitis, in the later stages of the disease the role of antibiotics is controversial.

[Treatment of glioblastoma multiforme]. / Zkusenosti s lécbou multiformního glioblastomu.

The authors evaluate therapeutic results in 31 patients with the diagnosis of multiform glioblastoma. The comprehensive therapeutic procedure used as a rule which involves surgery, radiotherapy and in some instances also chemotherapy still gives very unsatisfactory results. The mean survival period of patients after surgery was 26.7 weeks and the mortality of patients within one month was 22.6%. Even radical surgery does not produce more favourable therapeutic results. Contemporary trends of preclinical and clinical research are focused in particular on different immunotherapeutic methods.

[Subdural empyema. Present possibilities of diagnosis and therapy]. / Subdurální empyém. Soucasné moznosti diagnostické a lécebné.

The authors give an account of their experience with the diagnosis and treatment of subdural empyema. In 1953-1991 in the neurosurgical department in Olomouc a total of five patients with this diagnosis were treated. None of them died. In all patients before operation symptoms of meningeal irritation, fever and in four patients a focal neurological symptomatology was observed. The authors reached the conclusion that the best surgical approach is craniotomy or craniectomy which should be preferred to minor surgical operations. Treatment of the primary inflammatory focus leading to the development of subdural empyema must be part of the intracranial operation. Regular postoperative follow-up of the patient by means of CT makes it possible to detect in time relapses and leads to early surgical operation. The authors mention experience focused on possible errors in the CT diagnosis. The creation of the picture of subdural collection precedes oedema of the hemisphere with a shift of the structures in the median line. The subdural collection occurs in the subsequent stage of development of the disease.