Small keyhole transuncal foraminotomy for unilateral cervical radiculopathy.

Interbody fusion after anterior discectomy may lead to acceleration of degenerative changes at adjacent levels. Although the posterior approach preserves the motion segment, decompression of the nerve root is indirect if "hard disc prolaps" is the main cause. Recently, a technique of microsurgical anterior cervical foraminotomy for the treatment of radiculopathy with preservation of the segment mobility was published. In this study, we present this technique with several modifications.Thirteen patients - 5 men and 8 women with an average age of 49 years - with unilateral radiculopathy resistant to conservative treatment underwent microsurgical anterior foraminotomy via a small keyhole transuncal approach. The base of the uncinate process (UP) was directly drilled in the trajectory to the intervertebral foramen without destroying the disc tissue. The vertebral artery between the transverse process was not exposed. Furthermore, the functional anatomy of the uncovertebral joint remained largely intact. All patients experienced complete relief of radiating pain. A cervical collar was not used. Mean follow-up time was 19 months. The mobility of the operated segment was preserved in each patient. No instability of the cervical spine was seen. The microsurgical anterior foraminotomy via a small keyhole transuncal approach is safe, minimally invasive, and represents an effective method to treat unilateral cervical radiculopathy caused by disc prolaps and/or uncovertebral osteophytes. Additionally, the segment mobility is preserved and prevents the acceleration of degenerative changes at adjacent levels.

Stroke after initiation of interferon-beta treatment for relapsing-remitting disseminated white matter disease.

BACKGROUND: Interferon-beta (INF-beta) is effective and used in reducing exacerbation frequency and disease progression in multiple sclerosis. In certain circumstances, INF-beta can lead to rare side effects. AIMS OF THE STUDY: We report the case of a 34-year-old female patient satisfying the McDonald criteria of multiple sclerosis without showing typical pathologic changes in cerebrospinal fluid (CSF). After introduction of INF-beta treatment, she quickly developed further progression of her disseminated neurological symptoms and finally an ischemic cerebral infarction. METHODS: Evaluation of the patient included arterial angiography, magnetic resonance and positron emission tomography, histopathological assessment as well as a broad spectrum of serum and CSF analysis. RESULTS: All diagnostic evaluations and the clinical course revealed evidences for a primary angiitis of the CNS. We discuss the possible worsening due to inappropriate INF-beta treatment in cerebral angiitis promoting severe cerebrovascular insufficiency. CONCLUSION: The authors suggest that all diagnostic multiple sclerosis criteria including typical CSF findings should be ascertained before INF-beta treatment is initiated.

Autologous blood stem cell transplantation in refractory systemic lupus erythematodes with recurrent longitudinal myelitis and cerebral infarction.

Autologous hematopoietic stem cell transplantation (ASCT) has the potential to eliminate autoreactive lymphocytes and may represent a therapeutic option for patients with refractory autoimmune diseases. We describe a 19-year old woman with neuropsychiatric systemic lupus erythematodes (NPSLE) presenting with acute longitudinal myelitis and aseptic meningitis. Despite therapy with methylprednisolone and cyclophosphamide (CYC), recurrence of longitudinal myelitis and a disabling stroke-like relapse occurred. Hematopoietic stem cells were mobilized by CYC at 2 g/m2 and G-CSF. The patient was conditioned by CYC at 200 mg/kg and anti-thymocyte globulin and 3.6 x 10(6) CD34+ cells/kg were infused. Hematopoietic regeneration was observed on day 12 after ASCT. Currently, 18 months after ASCT, the patient is in clinical remission with no evidence for residual serological or neuroradiological activity of SLE. Although a longer follow-up will be needed to reliably assess the efficacy of ASCT in this patient, the present case demonstrates that ASCT may represent a therapeutic option for patients with severe NPSLE.

Novel neuroimaging findings in a patient with cerebral Whipple's disease: a magnetic resonance imaging and positron emission tomography study.

The authors report a 43-year-old patient with histopathologically proven cerebral Whipple's disease. Magnetic resonance imaging (MRI) revealed a multilayered left frontal lesion without mass effect, no perifocal brain edema, no contrast enhancement, and a thin shell of fluid signal that presented as an incomplete, open ring. An [11C]methionine positron emission tomography (PET) study showed low uptake below the threshold that is characteristic for brain tumors. In precise co-registration to the MR images, the PET data showed that increased uptake was mainly located in the direct adjacent part of the MRI lesion. The fluid signal on MRI corresponded to the extensive outflow of fluid from the lesion, which was observed during neurosurgical resection, and also to the neuropathological findings. The authors conclude that this cerebral manifestation of Whipple's disease made a unique and hitherto undescribed appearance on MRI; uptake pattern of PET amino acid tracer may help in the preoperative distinction of inflammatory from neoplastic lesions.

CT-guided percutaneous aspiration of Tarlov cyst as a useful diagnostic procedure prior to operative intervention.

Tarlov or perineural cysts are lesions of the nerve root most often found in the sacral region. Several authors recommend surgical treatment of symptomatic Tarlov cysts. However, successful surgical treatment is dependent on appropriate patient selection. In this article, we report three cases of a sacral perineural cyst, causing sciatic pain, and emphasize the usefulness of CT-guided percutaneous aspiration as an important diagnostic and prognostic procedure prior to definitive operative treatment.

[Can pharmaco-DSA of the kidney replace intraoperative rapid biopsy diagnosis?]. / Kann die Pharmako-DSA der Niere die intraoperative Schnellschnittdiagnostik ersetzen?

QUESTION: Can primary nephrectomy be performed without preliminary sample excision of the tumor if pharmaco-angiography of the kidney has demonstrated the typical tumor vascularization? MATERIAL AND METHOD: To clarify this question in 32 patients with "displacing mass" of the kidney, verified in sonography and computer-tomography, or hematuria of unknown origin, we prospectively performed and additional pharmaco-angiography of the respective kidney. RESULTS: In 18 patients with tumor vascularization in the pharmaco-angiography, intraoperatively we found 15 malignant renal cell carcinomas, 1 patient with transitional cell carcinoma of the renal pelvis, 1 leiomyosarcoma, and 1 high-differentiated tumor of only 2 cm in diameter with unclear dignity, which was treated by enucleation. CONCLUSION: In case of an intrarenal lesion of more than 3 cm in diameter and additional tumor vascularization seen in selective pharmaco-angiography, the kidney undoubtedly can be removed by primary nephrectomy without a preliminary sample excision to confirm the diagnosis. For tumors with a diameter of less than 3 cm and additional tumor-vascularization, the option should be enucleation. If there is a "tumor" without typical malignant vascularization, the exploration by sample excision should be performed. Depending on the histological result the tumor should be removed by enucleation or nephrectomy.