The quality of life of patients after a lumbar microdiscectomy: a four-year monitoring study.

INTRODUCTION/AIM: Health-conditioned quality of patients' life is equally a result of their subjective perception of the disease and their objective condition. The aim of this paper is to evaluate the quality of life of surgically treated lumbar radiculopathy patients by using a generic and a lumbar disease-specific questionnaire. METHODOLOGY: 50 patients were evaluated (average age: 44.9 years; 52 male and 48 female). Two questionnaires were used for this purpose: the SF36 generic questionnaire, measuring eight quality of life domains divided into two sub-domains (overall physical and overall mental health), and the NASS LBP lumbar disease-specific questionnaire measuring four domains (pain and disability, motor and sensory neurogenic symptoms, expectations from the treatment and satisfaction with it). The results of the physical domain (SF36-PHYS) are low at the beginning of monitoring (25.7); they increase over the following 6 months (46.4) and drop insignificantly after 4 years (45.9). The mental health value (40.4) remained unchanged as compared to that of the general population. Values of the physical functioning domain reach that of the general population (80.0) after 6 months. Neurogenic symptoms domain results (NASS LBP-NS) do not correlate with other scales and domains. The conclusion is that the quality of life of patients after a lumbar microdiscectomy deteriorates significantly from a physical point of view immediately after it. It normalizes over the following 6 months, though a certain degree of physical damage still remains. Mental health alteration is not specific for lumbar radiculopathy. The neurogenic symptoms domain is the least improved dimension of their quality of life: it is very specific and to be evaluated with a special test set.

A new scoring system for malignant astrocytomas.

BACKGROUND: Currently there are a few scoring systems for malignant astrocytoma, but they are not widely accepted. The aim of this study was to create a scoring system for supratentorial malignant astrocytoma, which could be used in both developed and developing societies. METHODS: This study was performed in 128 patients who had supratentorial malignant astrocytoma (grade III or IV). They were operated, and after the operation patients were irradiated with 50-60 Gy. FINDINGS: The mean age was 55.1 years. The mean Karnofsky performance status (KPS) was 51. The tumour removal >90% was achieved in 57.8%. A biopsy was never exclusively performed. The mean survival was 8.2 months and 12-month survival was 25%. Thirteen out of 35 data that we tested had a prognostic value for survival time. By using the most appropriate four parameters (age, KPS, initial seizure and histopathological grade) we created a scoring system - MAS (Malignant Astrocytoma Score). The scores range from 0-16. The area under the ROC (Receiver Operating Characteristic) curve showed that the AUC for the prediction of 6-, 12- and 18-month survival was 0.729, 0.755, and 0.927. We compared MAS with two of the most commonly used scoring systems. The AUC for the same prediction, using the MRC (Medical Research Council) was 0.673, 0.637, and 0.888. For the RTOG (Radiation Therapy Oncology Group) score the AUC was 0.672, 0.700, and 0.854. CONCLUSIONS: We are of the opinion that MAS represents a useful scoring system to determine the severity of the illness and make a prognosis for both individuals and groups of patients with malignant supratentorial astrocytoma. MAS is more accurate than predictions made by other systems currently in use; it includes prognostic factors that are widely accepted; it can be done at the patient's bedside and in clinics in developing societies.

[Recovery of facial nerve function using sural nerve transplantation after its injury in acoustic nerve surgery]. / Oporavak funkcije n. facialis-a prekinutog u toku operacije n. acusticus-a nakon transplantacije sa n. suralis-om.

INTRODUCTION: Statoacoustic n. neurinoma is a benign, slow-growing and usually unilateral tumor. During its growth the tumor exerts pressure on the surrounding anatomic forms within the pontocerebellar angle: cranial nerves, pons, cerebellum. Therefore the first clinical symptoms are ear buzzing and deafness, vision disorders, occipital headache or walking difficulties. The diagnosis of such conditions must be precise, whereas CT (computerized tomography) and MRI (magnetic resonance imaging) are the methods of choice. Surgical tumor removal is the only therapy, but during surgery facial nerve injury occurs. The objective of this paper is a case report of a facial nerve injury and sural nerve transplantation during acoustic neurinoma surgery and recovery of facial nerve function. CASE REPORT: A 23-year-old male patient suffered from ear buzzing in the right ear for a year and a half with gradual development of deafness. Due to frequent headaches and after ophthalmologic examination, the patient was urgently hospitalized at the Neurology Clinic of the Faculty of Medicine in Novi Sad where MRI of the endocranium was performed revealing a tumor of the pontocerebellar right angle, 3 x 3.5 cm in size. The patient has undergone surgery at the Neurosurgery Clinic of the Faculty of Medicine in Pees in Hungary, with suboccipital craniotomy and tumor ablation. During surgery facial nerve injury occurred in the premeatal segment and intraoperative transplantation of sural nerve grafts from the left leg to the distal parts of the facial nerve was performed. The histopathologic finding revealed an acoustic neurinoma (Schwannoma). After surgery a control CT was performed revealing a complete tumor removal. The wound healed per primam intentionem and the patient was released from hospital two weeks later. During the postoperative period physical therapy was performed in the aim of rehabilitation of the facial nerve due to peripheral paralysis. After electrodiagnostic tests using GALVOMED 20 apparatus, massage was performed in the periorbital and perioral regions. Kinesitherapy was also done in front of a mirror several times a day. 6 months after surgery an EMG (electromyography) of m. frontalis dx., m. orbicularis oculi dx. and m. orbicularis oris dx. were performed. The EMG revealed evident reinnervation possibilities. A year after surgery the control MR finding of the endocranium was regular, as well as the control MR two years after surgery (postoperative cyst without signs of recurrence of the removed neurinoma). Control EMG of the m. frontalis dx., m. orbicularis oculi dx., m. orbicularis oris dx. showed signs of reinnervation. DISCUSSION: Tumors of the pontocerebellar angle are usually acoustic nerve neurinomas. 8% of intracranial tumors are Schwannomas. They originate from neurilemmal cells, by rule they grow slowly and are benign tumors. Therefore, for years the only signs pointing to them are ear buzzing and gradual development of deafness. That is why these anamnestic data are important for diagnosis. Headaches, walking difficulties, vision disorders are the usual difficulties due to which patients seek doctor's help. Computerized tomography and magnetic resonance imaging represent the diagnostic methods of choice in establishing the diagnosis. In this case MRI was performed on time. Surgery is the only therapy, but during tumor ablation the facial nerve was injured in the premeatal region. Intraoperative transplantation of grafts taken from sural nerve to proximal and distal parts of the facial nerve provides possibilities for injured nerve regeneration. The process of regeneration of such a nerve is long-term and often permanent 40% axon loss occurs. This is the reason to perform a control EMG two years after surgery. During peripheral paralysis rehabilitation is performed in the aim of preventing contractures. It is achieved by passive exercises in front of a mirror a few times a day. (ABSTRACT TRUNCATED)

[Brain concussion--a minor craniocerebral injury]. / Potres mozga--laka kraniocerebralna povreda.

INTRODUCTION: Brain concussion is a brain dysfunction without any macroscopic structural damage, caused by mechanical force. This research paper presents the occurrence and basic characteristics of patients with brain concussion without skull fracture. The second aim of this paper is to answer questions, related to this problem, neurosurgeons are most often asked by doctors of other specialties. MATERIAL AND METHODS: Posttraumatic amnesia (patient unable to remember events before and/or after injury) was a condition to diagnose the brain concussion. In 1995 there were 240 patients with brain concussions without skull fracture at the Department of Urgent Surgery of our Institute. Eighty of them (33%) have been admitted to the Neurosurgical Clinic for observation and/or treatment. In all patients with brain concussion the following diagnostic procedure was applied: personal history, physical and neurological examination, basic blood tests and skull x-rays. CT imaging of the brain is not a routine because of our economic and technical circumstances. RESULTS: 240 patients were examined; 67% were males. Glasgow coma score (GSC) was 13-15 in all patients, while in nonhospitalized patients it was 15 (GSC = 15). 54% of patients were 15-40 years old; 35% were 41-60 years old and 11% were older than 60 years of age. Average hospitalization lasted for 3.48 days. According to the Glasgow outcome scale all patients had a good recovery. DISCUSSION: Patients with brain concussion have always amnesia with normal neurologic status. Legal and clinical definition of the minor head injury are not completely equal. Brain concussion is legally always a minor head injury. Patients with organic damage of brain (legally severe injury) can clinically look like having minor injury initially or till the end of the illness. Risk for brain damage in patients with amnesia is about 3%. Posttraumatic amnesia is always established by asking patients to remember events and not asking them if they were unconscious. Brain concussion is often associated with headache, vegetative or/and psychotic difficulties. Diagnostic protocol should comprise at least personal history, physical and neurological examination and skull x-ray. Consultation of a neurosurgeon and hospitalization are not indicated in all cases. In our series it was done in 33% according to indications which are established. In these cases patients should be transported with documents describing the type of injury, diagnostic results and treatment performed. The therapy is symptomatic. After brain concussion gradual return to everyday activities is indicated. Sick leave of 7-10 days is usually sufficient. Postconcussion syndrome (headache, vegetative or psychotic disturbances) occurs often and may last for a long period of time. CONCLUSION: We tried to describe a doctrine for diagnostic and treatment of patients suffering from brain concussion most appropriate according to our technical and economical circumstances.

[Expansive processes in the optic chiasm region]. / Ekspanzivni procesi optohijazmatske regije.

81 patients with expansive lesion in the optic chiasm region were reviewed. Pituitary adenomas were diagnosed in 37 patients: 5 with acromegaly, 2 with prolactinoma and the remaining 30 with hormone inactive adenomas. Meningiomas were diagnosed in 39, craniopharyngiomas in 4 patients and chordoma in one patient. The most common symptom was visual disturbance in 86%, but headache, hormonal disturbance occurred as well. All patients with adenomas were endocrinologically evaluated after detailed ophthalmologic and neurologic examinations. 28 patients were transcranially operated, 5 transsfenoidally and transcranially and 4 only transfenoidally. After endocrinologic reevaluation all patients with adenomas had undergone postoperative radiotherapy. Tumor recurrence was diagnosed in 14 patients, while 6 patients underwent reoperation. The approach to surgical regimen depended on the size and localization of meningioma. Unilateral subfrontal approach was most frequent (35). Subtotal tumor ablation was performed in 5 (13%) patients. Craniopharyngiomas were diagnosed in 4 patients (2 adults and 2 children). Total tumor ablation was performed only in one case.

[Surgical treatment of compressive lumbar radiculopathy]. / Operativno lecenje kompresivne lumbalne radikulopatije.

In the period 1982-1991, 1511 patients with compressive degenerative lumbar radiculopathy underwent surgery at the Clinic of Neurosurgery in Novi Sad. 1053 patients (69.69%) were operated due to radiculopathy of herniated disc etiology, 83 patients (5.50%) because od spondylotic radiculopathy and 38 patients (2.51%) because of spinal stenosis. 327 patients (21.64%) underwent surgery due to associated lesions, while 10 (0.66%) were operated because of other lesions. In patients with isolated disc herniations either interhemilaminectomy or extirpation of the degenerated pulp nuclei was performed, while in patients with spondylotic and stenotic radiculopathies most often decompressive laminectomy with facectomy and foraminatomy were performed. In cases of combined lesions combined surgical procedures were performed. There was no perioperative mortality. In 5 operated patients (0.33%) nonsurgical complications occurred, such as thrombophlebitis. Reoperation was performed in 94 patients (6.22%). Wound infection occurred in 4 patients (0.26%) and liquor fistula in 3 patients (0.20%). The paper presents diagnostic procedures, indications for surgical treatment and strategies.

[A completely organized extracerebral hematoma--case report]. / Potpuno organizov an ekstracerebralni hematom--prikaz slucaja.

Extracerebral hematomas, mostly caused by trauma, can be epidural or subdural according to their localization. According to their clinical picture they can be acute, subacute or chronic. Chronic epidural hematomas are extremely rare cases. Extracerebral hematomas are hemolyzed with time and fibrosis happens around them and, if not operated, they may appear finally as dural scars. Diagnostic and evolution of these hematomas can be presented by CT of the brain. They can be differential diagnostic problem in diagnosis of tumor of cranial bone, dura mater or brain. Definitive diagnosis is accomplished by pathoanatomic and pathohistologic examination. Treatment of these hematomas is mostly operative. This paper deals with a patient who suffered of completely organized dural scar that is very rare.

[Treatment of penetrating craniocerebral injuries from the Vukovar conflict, 1991-1992. Analysis of a series]. / Lecenje penetrantnih kraniocerebralnih povreda s Vukovarskog ratista, 1991-1992. Analiza serije.

Throughout the course of Vukovar conflict from July, 1991, to May, 1992, there were 37 patients with war craniocerebral injuries evacuated to our Clinic. 29 patients suffered penetrating missile craniocerebral injuries, in 14 (48%) there were fragment wounds and in 15 (52%) gunshot wounds. The series was analyzed according to wounding agents, sites of head penetration, CT scan findings, neurological findings, operative and postoperative complications, and mortality. We have found significant difference in mortality between wounded who sustained fragment wounds (14%) and those with gunshot wounds (27%). Further we emphasize the necessity of CT scanning, concerning a high haematoma incidence of 27 percent. Presence of retained in-driven bone or metal fragments in our series had no influence on development of either seizure disorder or an infectious complication. This supports a thesis of a limited brain debridement as a correct approach in the treatment of penetrating missile injuries.