Occipitocervical fixation in the management of craniocervical instabilities

The occipitocervical junction presents a unique, complex, biomechanical interface between the cranium and the upper cervical spine. Occipitocervical fixation has undergone significant evolution due to advances in operative techniques and instrumentation techniques. This study was done to evaluate clinical picture, radiographic findings and results of occipitocervical fusion in 10 patients with craniocervical instabilities. Also to compare these results with other results reported in the literature. This retrospective study reviewed 10 patients who underwent occipitocervical fixation for craniocervical instabilities between April 2007 and October 2010 in Alexandria hospitals. There were 7 males and 3 females and their ages ranged from 16 to 63 years with mean age of 42.1 years. As regards the clinical presentation, all patients had presented with neck pain before surgery, 8 patients [80%] with myelopathy, and 8 patients [80%] had presented with a neurological deficit either motor or sensory or both. The etiologies of occipitocervical instability in this study were trauma in three patients, rheumatoid arthritis in three patients, tumor in two patients and Down syndrome in two patients. All patients had preoperative craniocervical plain X-ray, CT and MRI examination. All patients underwent occipitocervical fixation surgery with various fixation systems and autologous bone grafts for fusion. Fusion was assessed by plain cervical X-ray films and CT scan, and the neurological outcome by Frankel grade. The mean follow-up period was 14.7 months [range, 4-24 months] including both clinical and radiological examinations. There were no operative mortalities or vascular injuries in this series. Two patients showed transient neurological deterioration postoperatively that had resolved within three months. Two cases had superficial wound infection and one case had cerebrospinal fluid leak. The mean operation time was 207 min [range 130-320 min] and the mean volume of blood loss was 354 mL [range 120-750 mL]. Neck pain improved in all patients and no new instability developed at adjacent levels. Regarding the Frankel grade, five patients had shown improvement [Three patients improved from Frankel grade C to grade D, one patient from grade A to grade B and one patient from grade D to grade E], while five patients remained stationary at the same grade. At the last follow-up examination period, a solid fusion was achieved in nine patients out of ten [90%]. Occiptocervical fixation is indicated in the management of craniocervical instabilities resulting from trauma, rheumatoid arthritis, tumors and congenital anomalies of the craniocervical junction. Accurate imaging studies and proper patient selection are the keys to a successful outcome. Occipitocervical fusion procedures can be performed with low morbidity. A comprehensive knowledge of the anatomy of the occipital-cervical junction is imperative. A wide variety of stabilization techniques and instrumentation systems are currently available, each of which has its own advantages and disadvantages

Management of essential hyperhidrosis of upper limbs by radiofrequency thermocoagulation of second thoracic ganglion

Essential hyperhidrosis is an idiopathic condition characterized by markedly excessive sweating especially in the hands. This study was done to evaluate the functional results of radiofrequency thermocoagulation of T2 ganglion in 10 patients suffered from essential hyperhidrosis of both upper limbs. This retrospective study was carried out on 10 patients suffered from essential hyperhidrosis of both upper limbs. The male to female ratio was 2 to 3 [4 males and 6 females] and their ages ranged from 16 to 28 years. Simultaneous palmar and plantar sweating was present in five patients [50%], simultaneous palmar and craniofacial hyperhidrosis in two patients [20%], and simultaneous palmar and axillary hyperhidrosis in one patient [10%], while palmar hyperhidrosis alone was found only in two patients [20%]. All cases underwent surgery in the form of radiofrequency thermocoagulation [RFT] of T2 on both sides under local anesthesia and sedation using C arm radiological guidance. Mean postoperative follow up examination period was 24 months. There was no operative mortality. Pneumothorax occurred on left side in one patient. Transient partial Horner's syndrome occurred on the right side in another patient. Postoperatively, 9 patients [90%] had clinical improvement of their palmar sweating. The last patient had partial improvement on right side and no improvement on the left side. The operation was repeated in one case with recurrence on the right side who improved. At the last follow up, excellent results were obtained in 90% of limbs, fair results in 5% of limbs, and poor results in 5% of limbs. The results of this study indicate that second thoracic ganglionectomy and sympathectomy performed with the use of percutaneous RFT is a very effective treatment for palmar hyperhidrosis that provide excellent immediate and long-term results as well as a low complication rate

Management of spastic hand by selective peripheral neurotomies

Selective peripheral neurotomies [SPN] are proposed when spasticity is focalized on muscles that are under the control of a single or few peripheral nerves. This study was done to evaluate the functional results of SPN of median and ulnar nerves in 10 patients who had spastic hyperflexion of the wrist and fingers. All patients preoperatively had spasticity either G3 or G4 as measured by modified Ashworth scale. All cases underwent surgery in the form of variable combination of SPN of median and ulnar nerves depending on the pattern and distribution of spasticity. Depending on the degree of preoperative spasticity, 50-80% of the isolated motor branches of fascicles were resected under the operating microscope. Mean postoperative follow up examination period was 21 months. There was no operative mortality. One patient had wound infection. Transient paresis of flexors of the wrist and fingers because of excessive nerves sectioning occurred in one patient that responded well to physiotherapy. Postoperatively, all the patients had immediate improvement of their spasticity grade. After initial improvement, recurrence of spasticity occurred in one patient 6 months postoperatively and that might be due to insufficient amount of nerve sectioning. Abnormal hand posture that was present in all cases improved in 9 patients [90%] postoperatively, while pain that was present in 50% of cases improved in all these cases postoperatively as measured by visual analogue scale. Assessment of outcome after surgery was done by comparing modified Ashworth scale preoperatively and postoperatively. At the last follow up examination period, excellent results were obtained in 40% of patients, good results in 40% of patients, fair results in 10% of patients, and poor results in 10% of cases. In well-selected patients, SPN can yield good effects on refractory spasticity of the hand and its consequences

Management of posterior fossa medulloblastoma in adults

Medulloblastoma is a malignant tumor of the cerebellum that occurs predominantly in children. It is rare in adults and accounts for less than 1% of all adult primary brain tumors. This study was done to study clinical picture, radiological findings, to evaluate the surgical outcome and to assess the effects of postoperative adjuvant therapy in 12 adult patients who had posterior fossa medulloblastoma This prospective study was carried out on consecutive 12 adult patients who had posterior fossa medulloblastoma. This study was done in Alexandria hospitals over a period of 3 years starting from March 2006 to March 2009. The male to female ratio was 2 to 1[8 males and 4 females] and their ages ranged from 19 to 51 years with mean age of 33, 8 years. Headache was the most frequent symptom [93, 5% of patients]. As regards the clinical presentation, manifestations of increased intracranial pressure was found in 10 patients [83, 3%], cerebellar dysfunction in 8 patients [66, 6%], cranial nerve deficits in half of the cases. The tumour was hemispheric in 10 cases [6 lateral and 4 paramedian] and vermian in 2 cases. All patients had preoperative craniospinal MRI examination. No distant or spinal metastases were detected in our patients at the time of diagnosis. All cases underwent surgery in the form of resection of the tumour followed by postoperative craniospinal irradiation. Also two patients with recurrence and metastases received adjuvant craniospinal radiotherapy and systemic chemotherapy. Mean postoperative follow up period was 24 months, including both clinical and MRI examination. There were no operative mortality, and surgery did not provoke any permanent neurological aggravation. Postoperative MRI studies showed complete tumour resection was achieved in 9 patients [75%]. After initial treatment only two patients relapsed in the posterior fossa after one and half year. Recurrence was probably related to incomplete tumor resection and long delay in initiating radiotherapy [3 months after operation]. Two of the patients that received adjuvant treatment died: one from distant metastasis and one from recurrent disease. Ten patients remained alive and disease-free with Karnofsky performance status ranging from 80 to100. Adult medulloblastoma was predominant in males and the majority of patients had hemispheric cerebellar tumors. Adults are more likely to have heterogeneous cerebellar tumours on MRI, and this is thought to be related to the greater prevalence of desmoplastic variant in adulthood. Long-term survival was not uncommon. The outcome depends on the site of the tumour with better results obtained in cases with lateral hemispherical tumour that facilitate its complete surgical resection and good irradiation planning

Transforaminal lumbar interbody fusion: surgical technique and early outcome

Objectives: This study was done to evaluate the functional outcome of transforaminal lumbar interbody fusion [TLIF] as a new technique for treatment of spondylolisthesis and degenerated lumbar disc disease, and the early outcome of the patients

Methods: This prospective study was carried out on 10 adult patients suffering from of spondylolysis and degenerated lumbar disc disease. The patients were admitted to the Alexandria university hospital over a period of 15 months starting from January 2005 to March 2006. The female to male ratio was 3 to 2, their ages ranged from 32 till 55 years with mean age of 42,5. All patients suffered from low back pain, while 9 patients showed signs of root affection and radiculopathy. All patients were subjected to preoperative, dynamic plain X-ray study and MRI of the lumbosacral spine. Eight patients [80%] had spondylolysis and the rest two 2 patients [20%] had degenerated lumbar disc disease. The level L4-L5 was affected in 6 patients [60%] while the level L5-SI was affected in 4 patients [40%]

Results: There was no operative mortality, and surgery did not provoke any permanent neurological aggravation. CSF leak was the mostfrequent postoperative complication [10%].After surgery 8 patients [ 80%] improved, and one patient [10%] stabilized, and one case [ 10%] suffered from exaggeration of back pain postoperatively, also all the patients were independent. Preoperative Prolo score was 14.4 and after surgery was 15.9

Conclusion: TLIF is a less invasive, reliable and safe technique for interbody fusion that can be performed with a posterior approach. It allows good decompression with minimal nerve root retraction. It restore the disc space height with preservation of the lumbar lordosis and augmentation of the posterior tension band via a screw-rod construct

Surgical choices for cervical OPLL

Ossification of the posterior longitudinal ligament [OPLL] is a common cause of cervical myelopathy, especially in Japan, and is more common in males. OPLL is classified into four types: segmental, continuous, mixed and focal. Different surgical approaches are being used to treat this disease, including laminectomy, laminoplasty and anterior, either resecting the ligament or decompressing the cord using the floating technique, leaving the ossified ligament in place. This study included sixteen patients with cervical OPLL treated at Alexandria main University Hospital during a period of two years [July 2001 to July 2003]. The age of the patients ranged from 45-67 years, with a mean age of 58.12 years. Fourteen patents were males and two were females. All patients excluding 2 presented with gradual progressive manifestations. The remaining 2 patients presented with acute onset quadriplegia after minor trauma. Upper extremity weakness and clumsiness, gait difficulty, sphincter dysfunction and neck pain were the most common complaints. Clinical evaluation and outcome of the patients was carried out using the Nurick scale. Fifteen of our patients suffered radiculomyelopathy. One patient with focal OPLL suffered radiculopathy in the distribution of right C6 root. Ten patients improved and six patients remained stationary during a follow-up period of six months. Plain x-rays, magnetic resonance imaging and computed tomography scan were done for all patients. Ossification posterior longitudinal ligament was found to be the continuous type in thirteen cases, mixed in two cases and focal in one. The maximal thickness of the OPLL was 7 mm with a range of 3-7 mm and a mean of 4.3 mm. The most commonly affected levels were C2-C4. The effective canal diameter ranged from 5-13 mm with a mean of 9.8 mm. In this study we used conventional laminectomy in eleven cases, open door laminoplasty in four cases and the anterior approach in only one patient with focal OPLL. We measured the improvement according to the Nurick scale. Ten patients improved and six patients remained stationary during a follow-up period of six months. We concluded from this study that OPLL should be kept in mind in the differential diagnosis in cases of cervical myelopathy. The effective canal diameter and the range of motion of the cervical spine are the most important factors affecting the clinical picture in cases of OPLL. Early surgery is recommended for cases of OPLL because better results are obtained in younger patients with short duration of symptoms. Laminectomy is a simple surgical option in cases of continuous type OPLL, with a stable spine as proved by dynamic study. Laminoplasty is better used in extensive involvement of the spine if the dynamic films show a high range of movement. Anterior approach has the risk of neural injury and is better avoided, especially if dural invasion could be identified in the preoperative imaging study. Anterior approach can be used in focal type OPLL and if used in extensive OPLL. The floating technique is safer than other methods to excise the OPLL

Management of adult tethered cord syndrome

This study was done to evaluate the surgical outcome of untethering of the cord in a consecutivec 10 adult patients suffering from tethered cord syndrome. This prospective study was carried out on consecutive 10 adult patients suffering from manifestations due to tethering of the cord. The patients were admitted to the Alexandria main university hospital over a period of 3 years starting from March 2002 to March 2005. The male to female ratio was 7 to 3 and their ages ranged from 25 till 57 years with mean age of 38.5. Most patients [9 patients] suffered from low back pain, while 7 patients showed signs of root affection and radiculopathy, sphincteric disturbances were present in all patients. Interestingly one patient had bilateral neuropathic ulcers at the site of the heel. All our patients developed signs and symptoms of tethered cord syndrome in adulthood. All patients were subjected to preoperative MRI of the lumbosacral spine, urodynamic study, and preoperative electrophysiological study of the lumbo-sacral plexuses. Intraoperative electrophysiological monitoring maneuvers using a bipolar stimulating electrode were used to identify functional neural tissue from the filum terminale and the response of lower limb muscles, and external anal sphincter were recorded either manually or by electromyography. Untethering of the cord using surgical microscope was done under general anesthesia without muscle relaxation. Dural graft was used in one case with secondary adhesions. Mean postoperative follow-up period was 15 months, including both clinical and MRI examination. The lower level of the conus was at lumbar vertebra L2 in one case, at L4 in 6 cases and at level from L5 to sacrum in 3 cases. The tethering lesions were tight filum terminale in 7 patients, lipoma in 2 patients, and secondary adhesions in one patient. Thickness of the filum was ranged from 1 to 7mm with a mean of 3.7mm. There was no operative mortality, and surgery did not provoke any permanent neurological aggravation of our cases. After surgery 2 patients [20%] were asymptomatic, 5 patients [50%] improved, and 3 patients [30%] stabilized, also all the patients were independent. The surgical outcome after tethered cord release in the adults is favorable, as most patients report improvement or stabilization of their symptoms. Safe surgical treatment with minimal complications and side effects can be achieved with the aid of intraoperative neurophysiological monitoring techniques. The success of surgery depends on early diagnosis and complete untethering of the spinal cord. It seems reasonable to recommend early surgical treatment in both symptomatic and asymptomatic adults