Pain outcome and vertebral body height restoration in patients undergoing kyphoplasty.

INTRODUCTION: Kyphoplasty, a minimally invasive technique, has recently been developed to provide immediate pain relief, biomechanical stabilization, prevention of fracture progression, vertebral height restoration, and prevention or reversal of kyphosis to patients with osteoporotic vertebral compression fractures (VCF). MATERIALS AND METHODS: We retrospectively reviewed 24 patients treated with kyphoplasty. A total of 37 vertebral levels were augmented. Visual analog scale (VAS) scores were documented in the immediate pre- and postoperative period, as well as 4, 12, and 72 weeks after the procedure. Vertebral body height restoration was assessed on postoperative x-rays. RESULTS: Mean preoperative VAS score was 9.3 and improved to 5.4 in the immediate postoperative period. At 4, 12 and 72 weeks post-operatively, mean VAS scores were 5.1, 5.9, and 6.1 respectively. All patients returned to their daily activities within 24 hours. No significant restoration of vertebral body height was observed. CONCLUSION: In regards to pain relief and postoperative functional outcome, kyphoplasty is a safe and effective treatment modality for osteoporotic VCFs, even when no significant restoration of vertebral body height is achieved.

Quantitative pupillometry: normative data in healthy pediatric volunteers.

OBJECT: The authors describe the prospective use of a new hand-held point-and-shoot pupillometer (NeurOptics) to assess pupil function quantitatively. METHODS: Repetitive measurements were made in 90 pediatric participants ranging in age from 1 to 18 years, providing a total of 100 measurements under ambient light conditions. The participants consisted of 45 patients without known intracranial or ophthalmological pathological conditions as well as 45 volunteers in the outpatient setting. Quantitative pupil measurements were reliably replicated in the study participants. The mean resting pupil aperture was 4.11 mm and the minimal diameter after stimulation was 2.65 mm, resulting in a 36% change in pupil size. The mean constriction velocity was 2.34 mm/second, with a mean dilation velocity of 2.2 mm/second. CONCLUSION: Pupil symmetry was impressive in the entire cohort.

Surgical treatment of acute type II and rostral type III odontoid fractures managed by anterior screw fixation.

OBJECTIVES: In the present study, the authors comment on their experience with anterior odontoid screw fixation in the management of odontoid fractures, in an attempt to further assess the safety and the efficacy of this procedure. MATERIALS AND METHODS: A retrospective analysis of 50 consecutive patients with reducible type II or rostral type III odontoid fractures, operated at our hospital with anterior odontoid screw fixation. Radiographic bony fusion, complications, and clinical outcome were evaluated. RESULTS: Solid bony fusion was evident in 38 (90.5%) of the patients. One mechanical instrumentation-related complication occurred, without clinical significance. No other major complications related to the procedure were noted. A satisfactory range of motion in the cervical spine was observed in all patients. CONCLUSIONS: Anterior odontoid screw fixation is a safe and effective procedure for the treatment of type II and rostral type III odontoid fractures. Compliance to the specific indications and contraindications of this operation is crucial for optimal outcome.

Postoperative cauda equina syndrome in patients undergoing single-level lumbar microdiscectomy. Report of two cases.

Cauda equina syndrome is a well-documented complication of uneventful lumbar microdiscectomy. In the vast majority of cases, no radiological explanation can be obtained. In this paper, the authors report two cases of postoperative cauda equina syndrome in patients undergoing single-level de novo lumbar microdiscectomy in which intraoperative electrophysiological monitoring was used. In both patients, the amplitudes of cortical and subcortical intraoperative somatosensory evoked potentials (SSEPs) abruptly decreased during discectomy and foraminotomy. In the first patient, a slow, partial improvement of SSEPs was observed before the end of the operation, whereas no improvement was observed in the second patient. In the first case, clinical findings consistent with cauda equina syndrome were seen immediately postoperatively, whereas in the second one the symptoms developed within 1.5 hours after the procedure. Postoperative magnetic resonance images obtained in both patients, and a lumbar myelogram obtained in the second one revealed no signs of conus medullaris or nerve root compression. Both patients showed marked improvement after an intense course of rehabilitation. The authors' findings support the proposition that intraoperative SSEP monitoring may be useful in predicting the development of cauda equina syndrome in patients undergoing lumbar microdiscectomy. Nevertheless, further prospective clinical studies are necessary for validation of these findings.

Literature review regarding the methodology of assessing third nerve paresis associated with non-ruptured posterior communicating artery aneurysms.

The association of third cranial nerve palsy subsequent to an enlarging posterior communicating artery (P-Com A) aneurysm has been well described. In our current communication, we review the relevant literature and propose a classification system for the severity of the third cranial nerve palsy, correlating it to the postoperative recovery. Our four grade scale (I-IV) included the degree of the levator palpebrae muscle paresis, the presence of pupillary reaction and the impairment of the third nerve mediated extraocular muscle movement. We evaluated five patients with third nerve palsy secondary to non-ruptured, P-Com A aneurysm. Patients were re-evaluated at 2, 4, 8, 24 weeks postoperatively. Four of the five patients had complete recovery within 4-8 weeks after surgery. One patient had grade II third nerve paresis and complete resolution of the third nerve symptoms within 4 weeks, whereas three patients with grade III and IV had complete resolution 4-8 weeks after surgery. The fifth patient, with grade IV paresis, had minimal (grade III) improvement 6 weeks after surgery, and incomplete recovery (grade I) 6 months postoperatively. Our simple grading system of third nerve palsy associated with P-Com A aneurysms, can be a helpful tool for the initial evaluation and for the monitoring of recovery in these patients.

Adult paravertebral pleomorphic rhabdomyosarcoma infiltrating diffusely the whole spinal axis. Case report.

The authors report a unique case of diffuse spinal metastatic disease due to a pleomorphic rhabdomyosarcoma (RMS) in an adult. In addition to its overall rarity, peculiar characteristics of the particular tumor included its site of origin, demonstrated radiologically as the lumbar paravertebral musculature (psoas muscle) and the transcanalicular spread into the vertebral canal, resulting in thecal compression at multiple levels. The salient clinicopathological characteristics of RMS, as they related particularly to the spine, are subsequently discussed and a short review of the major therapeutic modalities for these tumors is offered.

Results of long-term follow-up in patients undergoing anterior screw fixation for type II and rostral type III odontoid fractures.

STUDY DESIGN: Retrospective analysis of the fusion rate of a group of 38 patients having undergone anterior screw fixation for type II and "shallow" type III odontoid fractures. OBJECTIVE.: To determine primarily the long-term fusion rate after anterior screw fixation and to study the clinical characteristics of patients that have a statistically significant or nonsignificant influence on successful outcome. SUMMARY OF BACKGROUND DATA: Long-term outcome of anterior screw fixation for odontoid fractures has been evaluated in very few studies. This information should be critical for further establishing this technique as a major therapeutic strategy for these cases. METHODS: Thirty-eight patients, 25 males and 13 females (with mean age 48.4 +/- 0.4 years), with type II and rostral type III odontoid fractures, underwent anterior cannulated screw fixation during a 62-month period. Radiologic examination of the cervical spine with plain radiographs was performed at 6 weeks, and 2, 6, 12, and 24 months, while computerized tomography of the upper cervical spine (C1-C3) was obtained at 6 months after surgery. Follow-up was available for 31 patients, and the follow-up time ranged from 39 to 87 months (mean 58.4). RESULTS: Radiographic evaluation of the follow-up group showed satisfactory bony fusion and no evidence of abnormal movement at the fracture site in 27 (87.1%) patients. Pseudarthrosis developed in 4 (12.9%) patients; however, 3 (9.6%) of them without instability and 1 (3.2%) with instability. One (3.2%) patient had an instrumentation failure without instability. CONCLUSIONS: In our series, anterior odontoid screw fixation comprised a safe therapeutic modality with high stability and low mechanical failure rates during short-term and long-term follow-up.

Immediate and early postoperative pain relief after kyphoplasty without significant restoration of vertebral body height in acute osteoporotic vertebral fractures.

OBJECT: Painful osteoporotic vertebral compression fractures (VCFs) are a significant cause of disability in the elderly population. Kyphoplasty, a recently developed minimally invasive procedure, has been advocated for the successful management of these fractures in terms of immediate pain relief, and also for restoration of the premorbid level of daily activities. In this retrospective study the authors report on their experience with the early management of VCFs with kyphoplasty. METHODS: A retrospective analysis was conducted in 13 patients (seven women and six men) whose ages ranged from 48 to 87 years (mean age 71.5 +/- 11 years [mean +/- standard deviation]). The interval between onset of symptoms and surgical intervention ranged from 4 to 9 weeks. Twenty levels (12 thoracic, eight lumbar) were treated in this cohort. Immediate and early postoperative (1-month follow-up visit) visual analog scale (VAS) pain scores, activity levels, and restoration of vertebral body (VB) height were assessed. The mean preoperative VAS score was 8 +/- 1, whereas the immediate and early postoperative scores were 1 +/- 1. These findings reflected a resolution of 90 to 100% of preoperative pain. All patients resumed routine activities within hours of the procedure, although improvement in VB height was not accomplished in this cohort. No major complications were encountered in this clinical series. CONCLUSIONS: Kyphoplasty is a safe and effective method for the treatment of osteoporotic VCFs. Failure to restore VB height does not seem to interfere with the excellent pain management and good functional outcome provided by this procedure.

Is non-invasive monitoring of intracranial pressure waveform analysis possible? Preliminary results of a comparative study of non-invasive vs. invasive intracranial slow-wave waveform analysis monitoring in patients with traumatic brain injury.

BACKGROUND: An increasing body of evidence supports the concept that intracranial pressure (ICP) slow B waves represent the auto-regulatory response of spontaneous fluctuations of cerebral perfusion pressure. A relationship between cerebral auto-regulation and clinical outcome in patients with traumatic brain injury has also been established. The objective of our prospective clinical study was to compare the B slow ICP waves obtained invasively by standard ICP monitoring to those obtained noninvasively using a new ultrasound technology. MATERIAL/METHODS: In the participating institutions, over a period of six months, thirteen consecutive patients (8 males and 5 females) with severe closed head injuries (GCS < 8) were included in our IRB-approved study. Intracranial pressure and B slow waves, as well as arterial blood pressure and waveforms, were evaluated by standard invasive techniques. Additionally, a new non-invasive ultrasound device, Vittamed (Telematics Scientific Laboratory, Kaunas, Lithuania), was employed for monitoring intracranial blood volume slow waves. Using these modalities, it was possible to compare the changes that occurred with invasive monitoring (Correlation factor RI) and the changes that occurred using non-invasive technology (Correlation factor RN). RESULTS: Bland Altman plot analysis showed positive correlation between the invasively and non-invasively obtained slow intracranial B waves (2sigma = 8.9%, p < 0.0001) and cerebral auto-regulation indexes (RI and RN) (SD = 5%, p < 0.0001). Positive RI and RN values were correlated with poor clinical outcome. CONCLUSIONS: Ultrasonographic technology (Vittamed) may have significant application in non-invasive continuous cerebrovascular auto-regulation monitoring in patients with severe head injuries.

Correlation of the amount of disc removed in a lumbar microdiscectomy with long-term outcome.

STUDY DESIGN: The authors conducted a prospective clinical study. OBJECTIVES: The objectives of this study were to investigate the relationship, if any, of the amount of removed disc in a standard first-time lumbar microdiscectomy and long-term outcome as well as recurrence and postoperative instability rates. SUMMARY OF BACKGROUND DATA: There is lack of data on the amount of disc that needs to be removed during a lumbar microdiscectomy. Anecdotal data and dogmatic recommendations make the subject even more controversial. MATERIAL AND METHODS: A total of 106 patients underwent a standard first-time lumbar microdiscectomy for medically refractory sciatica resulting from a herniated disc. The removed disc material was weighted. All patients were clinically followed for at least 2 years and outcome was evaluated by using pain intensity, presence of physical signs, functional capacity, return to work, and patients' opinion regarding their outcome. RESULTS: The mean amount of disc removed was calculated at 2.1 +/- 0.9 g. Ninety-one patients had an excellent outcome and returned to their preoperative work. Fifteen patients had persistent symptomatology and underwent extensive radiographic workup, which revealed a disc recurrence at the same level in 8 patients and first-degree instability in 3 patients. In the remaining 4 patients, no clinical or radiographic abnormality was proven and the patients were treated conservatively, whereas all of them had applied for disability. No relationship was proven between the amount of the removed disc and the intraoperative blood loss or the intraoperative complication rate. Our statistical analysis showed no correlation between the amount of the removed disc and the long- term outcome, recurrence rate, or postoperative instability. CONCLUSIONS: The degree of disc removal did not influence the outcome or complication rate in our clinical series.

Does intraoperative electromyographic monitoring in lumbar microdiscectomy correlate with postoperative pain?

OBJECTIVES: Our objective was to correlate the findings of intraoperative electromyographic (EMG) monitoring with immediate postoperative pain in patients undergoing lumbar microdiscectomy. METHODS: A total of 112 patients undergoing de novo lumbar microdiscectomy were prospectively randomized into a control group (n = 45) and a study group (n = 67) in which intraoperative EMG monitoring was used. Postoperative pain and postoperative narcotic consumption were recorded for each patient. RESULTS: The presence or absence of EMG monitoring did not influence the level of reported pain in any anatomic area. In the monitored group, the degree of recorded nerve root irritation did not correlate with reported pain or postoperative narcotic consumption. The level of back pain was found to be significantly higher than the level of hip and calf pain (P < 0.0001). CONCLUSIONS: In our study no correlation was found between intraoperative EMG findings and immediate postoperative pain.

Cervical meningocele in association with spinal abnormalities.

CASE REPORT: This case report presents a newborn baby girl, who was diagnosed at birth with a mid-cervical meningocele. Further radiographic workup by MRI revealed co-existing thoracic diplomyelia and bilateral tethered cords. At birth the patient was found to be neurologically intact. Surgery was performed at 4 months of age, the patient undergoing simultaneous repair of the cervical meningocele, exploration of the diplomyelia, and release of the tethered cords bilaterally. Long-term follow-up revealed an ambulating patient with no bowel or bladder incontinence, who has developed well for her chronological age so far. REVIEW OF THE LITERATURE: A review of the literature relevant to this case is also presented.

Intracranial temperature: is it different throughout the brain?

INTRODUCTION: Accurate knowledge of cerebral temperature is assuming increasing importance, because its manipulation is employed more frequently for cerebral protection. PURPOSE: This prospective clinical study was performed to examine how well intraventricular temperature reflects global cerebral temperature. METHODS: The intraventricular temperature was monitored in 61 patients who were admitted to the neurointensive care unit for various intracranial pathological entities. A temperature probe coupled to an intraventricular pressure monitor was inserted in the lateral ventricle. At the conclusion of the monitoring process, a second intraventricular temperature probe was inserted in the ipsilateral ventricle and the previous one was carefully and gradually removed. During that removal, the intraparenchymal temperature was monitored for 90 minutes at 1-cm intervals throughout the brain parenchyma. RESULTS: The mean intraventricular temperature was 37.84+/-1.03 degrees C, whereas the mean systemic (rectal) temperature was 37.65+/-0.68 degrees C. At 1 cm outward distance from the lateral ventricle, the mean intraparenchymal temperature was 38.21+/-0.32 degrees C, 38.39+/-0.33 degrees C at 2 cm, 38.27+/-0.31 degrees C at 3 cm, 38.26+/-0.29 degrees C at 4 cm, and, finally, 37.9+/-0.50 degrees C at 5 cm. Statistical analysis of the recordings showed no statistically significant differences between the intraventricular and intraparenchymal temperatures and intraventricular and rectal temperatures. No statistically significant correlation was established between the intraventricular temperature and parameters, such as the patient's age, sex, and admitting diagnosis. CONCLUSION: Cerebral temperature was relatively stable through the brain parenchyma in this study. Because intraventricular temperature accurate.

New non-invasive sonographic modality for intracranial pressure/volume monitoring.

INTRODUCTION: The wide use of intracranial pressure and cerebral perfusion pressure monitoring has improved the management of patients with severe head injuries. The rare but worrying complications associated with the application of such monitoring makes the idea of a non-invasive method of monitoring very attractive. MATERIALS AND METHODS: A new non-invasive ultrasonographic technology was used to measure cerebral perfusion pressure in 27 normal volunteers. The average monitoring time was 45.3+/-0.2 min, and the average perfusion pressure recorded was 77.4+/-0.3 mmHg. No complications were reported during the procedure, which was performed while the subjects were in regular ward beds. CONCLUSION: The non-invasive character of this method could extend the use of cerebral perfusion pressure measurement to several other neurosurgical entities, such as hydrocephalus, pseudotumor cerebri, chronic headache, and spinal cord injuries.

Effects of nerve root retraction in lumbar discectomy.

UNLABELLED: The authors studied whether the amount of retraction pressure applied to a compromised nerve root during lumbar discectomy has an impact on intra- or postoperative outcome. METHODS: The authors conducted a prospective analysis of 20 patients. There were 12 men and 12 women whose mean age (+/- standard deviation [SD]) was 42.25 years +/- 15 years (range 21-65 years). During intraoperative electromyography (EMG) monitoring, measurements were obtained during routine retraction of the affected nerve root by using a specially designed and constructed nerve root retractor connected to a reconfigured personal computer for this specific purpose. Follow-up results were assessed in the immediate postoperative period and at up to 1 year. The maximum measured force applied during random periods of time was 9.85 N/second (mean 6.95 +/- N/second [+/- SD]). The mean retraction time was 39.5 +/- 21 (SD). No intraoperative EMG-detected irritation was noted during or after routine retraction. In four of 20 patients, sensory changes occurred at the ipsilateral nerve root level, which resolved at the time of discharge. CONCLUSIONS: The authors found that routine nerve root retraction does not cause nerve root irritation, as demonstrated by EMG monitoring, nor was patient outcome affected in this series.