Does lumbar spinal decompression or fusion surgery influence outcome parameters in patients with intrathecal morphine treatment for persistent spinal pain syndrome type 2 (PSPS-T2).

OBJECTIVES: Intrathecal morphine pump (ITMP) infusion therapy is efficient in managing chronic pain refractory to standard treatment. This study evaluates pain relief and improvement of quality of life in chronic pain patients after intrathecal morphine pump implantation for treatment of persistent pain after lumbar spinal fusion surgery and lumbar spinal decompression alone. METHODS: Forty three chronic pain patients that received an ITMP at our department between 2009 and 2019 were retrospectively analyzed divided into 2 cohorts (lumbar spinal fusion surgery and lumbar spinal decompression alone). Pain intensity was evaluated using the numeric rating scale (NRS), quality of life was assessed by EQ-5D-3L, mental health was assessed by Beck Depression Inventory (BDI-V), and Pain Catastrophizing Scale (PCS). Morphine dosage was assessed over time. Data was collected preoperatively, 6 and 24 months postoperatively. Statistical analysis was performed using Friedman's analysis of variance to evaluate the development of NRS, PCS, BDI and EQ-5D-3L over time and Mann-Whitney-U-test for the differences between these parameters in the different cohorts. A two-sided p-value <0.05 was considered statistically significant. RESULTS: Median age was 64 years (IQR25-75 56-71 years). NRS, EQ-5D-3L, BDI-V, and PCS showed a significant overall improvement after 6 and 24 months compared to baseline data (p<0.001). No statistically significant differences between patients with lumbar spinal fusion surgery and lumbar spinal decompression alone were seen. Furthermore, no statistically significant differences for age and gender were seen. The initially administered median morphine dosage was significantly higher in the fusion group (3.0 mg/day; IQR25-75 1.5-4.2 mg/day) compared to the decompression-alone group (1.5 mg/day; IQR25-75 1.0-2.6 mg/day); (p=0.027). CONCLUSIONS: This retrospective study showed that ITMP have a major long-term impact on pain relief, improve the quality of life, psychological distress, as well as pain catastrophizing in patients with chronic pain following lumbar spinal surgery independent of the previous surgical procedure. After ITMP implantation initial median morphine dosage seems to be significantly higher after spinal fusion compared to decompressive surgery alone.

Neurosurgical shunt treatment of pediatric hydrocephalus: epidemiology and influencing factors on revision surgeries: a single-center retrospective analysis of 131 patients.

BACKGROUND: Paediatric hydrocephalus is a result of a dysfunction of cerebrospinal fluid circulation, and it has diverse pathogeneses. This study investigates the epidemiology of paediatric hydrocephalus, as well as the influences of primary aetiology and implant type on treatment complications and the development of new therapeutic approaches and strategies. METHODS: Between 2013 and 2018, a retrospective analysis of 131 children, who were suffering from hydrocephalus, was conducted. Medical charts, operative reports and clinical follow-up visits were reviewed. Statistical analysis was performed using t-test/ANOVA and Kruskal-Wallis test/Mann-Whitney U test. RESULTS: The most common pathogeneses of hydrocephalus among our patients were meningomyelocele-associated and posthaemorrhagic. The majority of patients received a programmable differential pressure valve (PPV, 77.8%) or a fixed differential pressure valve with a gravitational unit (FPgV, 14.8%). Among 333 shunt-associated surgeries, 66% of surgeries were revision surgeries and were performed because of mechanical shunt dysfunction (61%), infection (12%), or other reasons (27%). The median rate of revisions within one year for each patient was 0.15 (IQR25-75: 0.00-0.68) and was influenced by aetiology (p = 0.045) and valve type (p = 0.029). The highest rates were seen in patients with posthaemorrhagic hydrocephalus and in those with FPgVs; the lowest rates were seen in patients with meningomyelocele-associated hydrocephalus and PPVs. The occurrence of mechanical dysfunctions was correlated with FPgV patients (p = 0.014). Furthermore, the median time interval between initial shunt surgery and onset of infection was shorter than that between initial surgery and mechanical dysfunction (p = 0.033). CONCLUSIONS: Based on this research, we can state several factors that influence revision surgeries in paediatric shunt patients. With the assessment of patients' risk profiles, physicians can classify paediatric shunt patients and thus avoid unnecessary examinations or invasive procedures. Furthermore, medical providers can prevent revision surgeries if they choose shunt material in accordance with a patient's associated shunt complications.

A prospective randomized study comparing retractor-endoscopic vs. open release of carpal tunnel and cubital tunnel syndromes.

OBJECTIVE: To evaluate the neurological and neurophysiological outcomes of retractor-endoscopic versus open release in carpal tunnel syndrome (rCTS and oCTS, respectively) and cubital tunnel syndrome (rCbTS and oCbTS, respectively) at 3- and 12-month follow-up. METHODS: Between 2013 and 2017, 80 patients were prospectively blindly randomized. McGowan scores were used for preoperative grading and outcomes were assessed using a modified Bishop rating system (BRS). Furthermore, incapacity to work, duration of postoperative pain, hypoesthesia, atrophy, subjective weakness, and a subjective assessment of the operative result were analyzed. The differences in the cohorts were evaluated with t-tests and ANOVAs as parametric tests and Kruskal-Wallis and Mann-Whitney U tests as nonparametric tests. RESULTS: The 80 patients underwent retractor-endoscopic or open decompression of the median or ulnar nerve. The rCTS group exhibited significant improvements in neurophysiological data (P = 0.032), shorter periods of postoperative pain (P = 0.03), and less discomfort (P = 0.005), as well as significantly better BRS results after 3 months compared with the oCTS group (P = 0.005). Between the oCbS and rCbTS groups, no significant differences were observed (P > 0.05). Regarding improvements in McGowan scores, no statistically significant differences were observed between the rCTS and oCTS groups after 3 months (P = 0.52) or 12 months (P = 0.86), nor were any observed between the rCbTS and oCbTS groups after 3 months (P = 0.88) or 12 months (P = 0.10). CONCLUSION: Significantly superior results were obtained at short-term follow-up for rCTS, whereas no superiority was found for rCbTS release. This study concluded that this endoscopic procedure is safe as well as and effective and has the potential to achieve better results in carpal tunnel syndrome compared with conventional methods.

Serum Lactate as Serum Biomarker for Cardiopulmonary Parameters within the First 24 Hours after a Spontaneous Intracerebral Hemorrhage.

Objective: Cardiopulmonary (CP) complications are well known in patients with an intracerebral hemorrhage (ICH) and could be associated with a higher serum lactate level. The present study aimed to assess the associations between the initial serum lactate level and the CP parameters within the first 24 h of intensive care unit (ICU) treatment in neurosurgical ICH patients. Patients and Methods: A total of 354 patients admitted to the ICU between 01/2009 and 12/2017 with a diagnosis of an ICH were retrospectively analyzed. Blood samples were taken upon admission, and each patient's demographic, medical, and radiological data upon admission, as well as several CP parameters, were recorded within the first 24 h of ICU treatment. Results: A higher serum lactate level was associated with a lower GCS score (p < 0.0001), as well as a higher Acute Physiology and Chronic Health Evaluation II score (p = 0.002) upon admission. Additionally, patients with initially higher serum lactate levels had a significantly higher need for a norepinephrine application (p = 0.004) and inspiratory oxygen fraction (p = 0.03) within the first 24 h. Conclusion: Neurosurgical ICH patients with higher serum lactate levels upon admission require more CP support within the first 24 h of ICU treatment.

ZEB1 induces N-cadherin expression in human glioblastoma and may alter patient survival.

The present study investigated the expression of epithelial-mesenchymal transition (EMT)-related factors zinc finger E-box-binding homeobox 1 (ZEB1), cadherin-1 (CDH1), cadherin-2 (CDH2) and the cell cycle modulating kinase cyclin-dependent kinase 1 (CDK1) in human glioblastoma (GBM) compared to normal brain tissue, as well as whether the levels of expression were associated with the overall and progression-free survival of the GBM patients. In 44 GBM and five normal brain tissue specimens, the expression levels of ZEB1, CDH1, CDH2 and CDK1 were evaluated by real-time PCR and immunostaining, and the results were correlated with clinical data. The expression levels of all investigated genes as detected by immunostaining were significantly higher in the GBM when compared to the normal brain tissues. There was no influence on survival. A linear correlation between ZEB1 and CDH2 and CDK1 expression was observed in GBM. Moreover, ZEB1 was involved in EMT (e.g., signaling in human GBM) and high ZEB1 levels were linked to an aberrant cell cycle processing, marked by CDK1 overexpression.

Preoperative Elevated Levels for Depression, Anxiety, and Subjective Mental Stress Have No Influence on Outcome Measures of Peripheral Nerve Field Stimulation for Chronic Low Back Pain-A Prospective Study.

OBJECTIVE: Peripheral nerve field stimulation (PNFS) is an effective alternative treatment for patients with chronic low back pain. The treatment of low back pain strongly depends on psychological factors like anxiety, depression, and mental stress. The aim of this study was to evaluate the impact of such factors on outcome measures after lead- and implantable pulse generator-implantation. MATERIALS AND METHODS: Between 2014 and 2019, a prospective cohort study of 39 patients with chronic lumbar pain was conducted. Hospital Anxiety and Depression Scale (HADS) score was assessed at baseline to measure symptoms of anxiety and depression. Symptom checklist-90 (SCL-90) was used to measure subjective psychopathology. Pain intensity (numeric pain rating scale [NRS]), SF12v2 with Physical Component Summary and Mental Component Summary (MCS) scores, and Oswestry Disability Index (ODI) were assessed pre- and postoperatively as well as three and six months after PNFS implantation. Outcome values were compared to baseline data. Statistical analysis was performed using depending t-test and analysis of variance (ANOVA). A p value <0.05 was considered significant. RESULTS: The cohort consisted of 39 patients (18 females, 21 males) with a median age of 61 years (IQR25-75  = 52-67 years). NRS, ODI, and SF12v2 showed significant improvement in the whole follow-up period compared to baseline values (p < 0.05). Elevated HADS scores for anxiety were seen in 64.1%, for depression in 76.9% of the patients at baseline. SCL-90 was pathologic in 71.8% of the cases. A one-way ANOVA revealed no differences between elevated HADS- and SCL-90 values and all outcome measures after PNFS implantation in the whole follow-up period (p > 0.05). CONCLUSION: Chronic low back pain is often associated with psychological distress. Our study showed highly elevated levels for anxiety and depression as well as subjective mental stress in patients with chronic low back pain without negative impact on NRS, ODI, and SF12v2 in the whole follow-up after PNFS implantation.

The Predictive Value of Transcutaneous Electrical Nerve Stimulation for Patient Selection in Peripheral Nerve Field Stimulation for Chronic Low Back Pain: A Prospective Study.

OBJECTIVE: Peripheral nerve field stimulation (PNFS) is an effective alternative treatment for patients with chronic low back pain. Transcutaneous electrical nerve stimulation (TENS) is frequently used in pain therapy. Aim of this prospective study was to examine the predictive value of TENS for later PNFS treatment. MATERIALS AND METHODS: Between 2014 and 2019, a prospective cohort study of 41 patients with chronic lumbar pain was conducted. Pain intensity (NRS) was assessed before and after TENS use, preoperatively/postoperatively and in the follow-up after three and six months, SF12v2 questionnaires with physical (PCS) and mental component summary (MCS) scores, and Oswestry disability index (ODI) questionnaire at baseline as well as three and six months after PNFS implantation. Implantation of the PNFS-system with two percutaneous leads was performed after four to seven days of positive testing. Statistical analysis was performed using depending t-test, ANOVA, and Spearman correlation. RESULTS: The cohort consisted of 41 patients (19 females, 22 males) with a median age of 60.5 years (IQR25-75 52-67). Two patients were lost to follow-up. After positive PNFS testing a pulse generator (IPG) was implanted in 15 patients with positive TENS effect and 15 patients without TENS effect. Leads were explanted in nine patients after negative PNFS trial phase. TENS positive patients showed significant correlation to a positive effect in the PNFS trial phase in NRS reduction (p = 0.042) indicating that TENS responders will also respond to PNFS (94% patients). After three and six months follow-up median NRS and SF12v2 (PCS) improved significantly in both cohorts, SF12v2 (MCS) and ODI only in the TENS positive cohort, respectively. CONCLUSION: TENS can be predictive for patient selection in PNFS, as TENS positive patients showed significant correlation with a positive PNFS trial period. Therefore, TENS positive patients might be justifiable to be directly implanted with leads and IPG. TENS positive patients further tend to show a better improvement in the follow-up.

Interdisciplinary Laparoscopic Implantation of Neuromodulation Leads to the Sacral Plexus for Therapy of Chronic Pelvic Pain and Neurogenic Bladder Dysfunctions.

OBJECTIVE: The aim of this study was to report on the use of laparoscopic implantation of leads on the branches of the sacral plexus for neuromodulation in the treatment of chronic pelvic pain (CPP) in a multidisciplinary setting with the help of electrophysiological neuromonitoring. MATERIALS AND METHODS: Between 2012 and 2019, six female patients complaining of chronic pain and bladder and bowel dysfunctions underwent laparoscopic exposure and nerve identification with the help of electrophysiological neuromonitoring. A lead was placed laparoscopically in direct contact with the affected nerve. Pain intensity (numerous ranking scale [NRS]), generic health status (EQ-5D-5L), Becks Depressions Inventory (BDI-V), Pain Catastrophizing Scale (PCS), and Client Satisfaction Questionnaire (CSQ-8) were assessed pre-/postoperatively as well as three and six months after surgery. Statistical analysis was performed using Mann-Whitney U and Wilcoxon rank-sum test. RESULTS: The median age was 36.5 years. NRS improved from a median of 9.5 preoperatively to 3.0 (p < 0.001) at six-month follow-up. Median EQ-5D-5L index value before treatment was 0.18, indicating a notably lowered quality of life and increased up to 0.83 after six months (p < 0.001). Preoperative median BDI-V scores indicated a major depressive mood and improved from a median of 46.0 to 12.0 after six months (p = 0.007). Preoperative PCS was elevated with a median score of 41.0 and decreased to 4.0 after six months (p < 0.001). CSQ showed that patients were satisfied with the treatment. CONCLUSIONS: This unique method is an alternative and effective treatment option for CPP even years after primary endometriosis surgery.

Programmable valve breakage in shunt systems of children with posthemorrhagic hydrocephalus after minor head trauma-a case series.

PURPOSE: We report five rare cases of programmable valve breakage (Codman Hakim-Medos valve) in shunt systems of children with posthemorrhagic hydrocephalus. Only four similar studies have been published in the current literature. METHODS: Between 2013 and 2018, five children with posthemorrhagic hydrocephalus were admitted to the pediatric department. All patients had a history of slight blows to the head in a minor trauma and follow up MRI scans. After initial clinical examination, cranial computed tomography (CT) and X-ray were conducted. RESULTS: In all cases, pumping the reservoir resulted in very slow refilling. The cranial CT in one patient showed slit ventricles confirming the suspicion of overdrainage, the other cases a slight enhancement of the hydrocephalus. In lateral X-rays of the skull in comparison to the first X-ray control of the shunt valve, the pressure control chamber could be seen dislocated in the inferior part of the reservoir in all cases. Surgery revealed that the shunt valve was broken. The pressure control chamber had dropped to the bottom of the reservoir. After implantation of a new shunt valve, the symptoms resolved completely in all five children. Overall this complication occurred in 4.3% (5 of 85 implanted Codman Hakim-Medos valve) of all children necessitating ventriculoperitoneal shunt implantation between January 2013 and December 2018. CONCLUSION: The well-accepted Codman Hakim-Medos programmable valve is part of a tube-system, which is designed to offer the possibility of a reliable and precise treatment of hydrocephalus. Various mechanical and non-mechanical complications of shunt systems have been reported. Valve breakage is a very rare condition, often missed, and must be kept in mind when trauma and prior MRI scan are reported.