[Correction of kyphotic deformity of the cervical spine in ankylosing spondylitis using pedicle subtraction osteotomy of the seventh cervical vertebra]. / Korekce kyfotické deformity krcní pátere pri ankylozující spondyloartritide pedikl subtrakcní osteotomií sedmého krcního obratle.

PURPOSE OF THE STUDY: The aim of the study is to present the technique of pedicle subtraction osteotomy (PSO) of the seventh cervical vertebra (C7) for correction of rigid kyphotic deformity of the cervicothoracic junction (C/Th) in patients with severe ankylosing spondylitis (AS).. MATERIAL AND METHODS: The PSO technique for correction of rigid deformity of the C/Th spine was used in five patients with the aim to restore their ability of horizontal vision. The follow-up in all patients lasted two years at least. Clinical assessment of treatment results was based on the patients' neurological status and their satisfaction with the correction achieved. Improvement in a vertical 2) line of sight was evaluated using the angle measured between the forehead-chin line and the vertical (FCv angle) in a lateral view photograph of the standing patient. The achieved correction of kyphotic deformity was assessed by comparing the pre-operative Cobb's angle between the second cervical and the fourth thoracic vertebra with the post-operative one. RESULTS: The average operative time was 4 hours (range, 3.5 to 5 h). The average blood loss was 1600 ml (range, 800 to 2100 ml). On the average, the FCv angle was reduced by 45.2° and Cobb's angle was corrected) by 54.6°. All patients were satisfied with the degree of correction achieved and reported alleviation of neck pain. none of the patients showed any significant loss of correction or neurological deterioration at two-year follow-up. DISCUSSION: The theoretical and technical principles of corrective osteotomy at the C7 level performed for rigid kyphotic deformity of the spine at the C/Th junction are presented in our group of patients. Our results give support to the superiority of instrumented PSO used currently over the previous techniques. In accordance with the relevant literature data, attention is drawn to a relatively higher risk of this procedure in comparison with corrective surgery performed at the other spinal levels. CONCLUSIONS: Corrective osteotomy of a rigid kyphotic deformity at the C/Th spine level in AS patients involves a complex reconstructive surgical procedure. The PSO technique reduces the risk of injury to the visceral structures ventral to the spine, and provides optimal conditions for bone healing at the site of vertebral body resection. If the patient heals well, a successful PSO procedure will markedly improve the quality of his/her life.

Carotid endarterectomy and carotid artery stenting: changing paradigm during 10 years in a high-volume centre.

BACKGROUND: We analysed the results of internal carotid artery (ICA) stenosis treatment at our institution over the last 10 years according to treatment modalities (carotid endarterectomy [CEA] vs carotid artery stenting [CAS]). Furthermore, we compared our results of treatment prior to the EVA-3S study being implemented into our practice (2003-2007) and after that (2008-2012). METHOD: During the years 2003-2012, a total of 1,471 procedures were performed for ICA stenosis. CEA was done in 815 cases and CAS in 656 cases. The primary outcome was disabling stroke (mRS > 2) or myocardial infarction (MI) within 30 days after treatment. Secondary outcomes were frequency of transient ischaemic attacks (TIAs), minor strokes (stroke without impaired activities of daily living [ADL]) and any other significant complication. Comparisons of the results before and after 2008 were performed. RESULTS: Major mortality and morbidity were divided according to treatment groups; reached 1.0 % in the CEA group and 3.0 % in the CAS group, p = 0.004. Minor stroke was recorded at 1.8 % and 2.7 % in the CEA and CAS, p = 0.245. TIAs in 1.0 % (CEA) and 4.7 % (CAS), p < 0.001. Any complication in 11.9 % (CEA) and 13.3 % (CAS), p = 0.401. In the overall results (i.e. CEA and CAS together), we found in 2008-2012 a decrease of incidence of TIAs (from 30/840 to 9/631, p = 0.011) and any complications (from 120/840 to 64/631, p = 0.017). CONCLUSIONS: CEA performed in a high-volume centre is a safe procedure in properly indicated patients. In all subgroup analyses, CEA fared better than or at least of equal benefit as CAS. Since 2008, the frequency of TIAs and other complications decreased significantly. This study supports an idea of CEA being the first choice of treatment and CAS being reserved for strictly selected cases, such as re-stenosis after a previous carotid procedure, carotid dissection, ICA stenosis after radiotherapy, previous major neck surgery, contralateral cranial nerve palsy or tandem stenosis.

[The significance of biological intracranial meningioma behaviour for their long-term management]. / Význam biologického chování nitrolebních meningiomu pro jejich dlouhodobý management.

INTRODUCTION: From the histological point of view, most meningiomas are benign tumours. Nevertheless, their recurrence is quite frequent, and identifying the risk factors for recurrent disease is of utmost importance. MATERIAL AND METHODS: Prospective study, patients operated on in the period 2/2008-9/2009. Inclusion criteria for enrolment into the study: age 18-70 years, good health status, and previously untreated solitary intracranial meningioma. Evaluation of clinical, surgical, MRI findings and vascular endothelial growth factor serum levels (prior to procedure, 3 months after, 12 months after, 24 months after procedure and at the time of the last follow-up in 11/2011) was performed. Immunohistochemical analysis of histological samples was carried out. Further treatment (wait and see, redo surgery, treatment with radiation using the Leksell Gamma Knife, external radiotherapy) was recorded in case of a positive follow-up MRI finding (recurrent disease, progression of residual tumour). RESULTS: A total of 50 consecutive patients (34 women and 16 men) were included into the study. Average age at the time of surgery was 59.2 years (range 27-75 years). Radical resection with no residual tumour left was achieved in 35 cases. Histological analysis showed grade I meningioma in 45 cases and grade II (atypical) meningioma in 5 cases. Correlation between E-cadherin expression and recurrent meningioma was proved by immunohistochemical examinations; in the remaining investigations, however, such a correlation was not found. No correlation was detected between the serum vascular endothelial growth factor level and the expression of vascular endothelial growth factor in immunohistochemical investigation. A correlation was found between the expression of vascular endothelial growth factor in immunohistochemical investigation and peritumoural oedema. The tumour recurred in 5 cases. CONCLUSIONS: On the basis of our results as well as literature findings we can conclude that all the patients after meningioma surgery need to be carefully followed for the rest of their life by repeated MRI invetigations.

Hypercapnia impact on vascular and neuronal reactivity in patients before and after carotid endarterectomy.

HYPOTHESIS: Regional cerebral blood flow (rCBF) and vascular reactivity strongly affect neuronal function. The restoration of blood flow values in the cerebral vascular system may be another benefit of carotid endarterectomy (CEA) in a specific group of patients. Animal experiments in dogs have provided evidence of neuronal reactivity depending on rCBF and vascular reactivity. However, as yet, there are no reports on neuronal reactivity changes related to altered perfusion parameters in humans. MATERIAL AND METHODS: The cohort under study consisted of 41 patients after transient ischaemic attack (TIA) or reversible ischaemic neurological deficit (RIND) whose neurological findings were normal (group A) and 17 patients after minor stroke with a mild degree of hemiparesis or hemihypesthesia (mRS

Experience of 500 cases of neurophysiological monitoring in carotid endarterectomy.

BACKGROUND: Experience with Intraoperative monitoring using neurophysiological and haemodynamic indices in 500 operations for carotid endarterectomy is reported. METHODS: Transcranial Doppler technique (TCD), electroencephalogram (EEG) and bilateral median somatosensory evoked potentials (SEP) were performed. Latency and amplitude of SEP, spectral analysis of EEG signal and blood flow velocity in the medial cerebral artery (MCA) were continuously measured. FINDINGS: After two consecutive drops of N20/P25 complex of more than 50%, a warning was given, and when the decrease continued, an the alarm raised. Abnormal EEG changes, if any, appeared after a significant decrease in the N20/P25 amplitude. A mean blood flow velocity drop below 40% of the reference value after cross clamping was rated as a significant warning event.A warning as a result of a decrease in N20/P25 amplitude occurred in 80 operations (16.0%), after an spectral edge frequency decrease in 2 cases (0.4%) and after a V(mean) decrease in 21 cases (4.2%). False negative results were experienced in 2 patients (0.4%). A shunt was inserted in 2.8% of the operations. The overall mortality/morbidity rate was 2.4%. CONCLUSION: A decrease of more than 50% in the amplitude of the thalamocortical somatosensory evoked potential complex N20/P25 proved to be the most reliable warning of danger of ischaemia during carotid endarterectomy.

Evaluation of a limited drug formulary in an adult internal medicine clinic.

The utility of a 30-drug, limited formulary in an adult internal medicine, ambulatory-care clinic was investigated. The formulary was developed using a mail survey of a random sample of members of the ASHP Ambulatory Care Pharmacy Practice Special Interest Group. The consensus formulary comprised the 30 most frequently recommended drugs; the utility of the formulary was then tested by chart review in a primary-care internal medicine clinic. Over a two-month period, the charts of alternating patients were reviewed daily; patient data collected included demographic information and prescribed drug therapy. A panel of two physicians and one pharmacist reviewed each patient's data and determined the appropriateness of drug treatment. If an agent was prescribed that was not on the consensus formulary, the panel determined whether an appropriate formulary agent could have been prescribed. Of the prescribed drug orders, 57.8% were for agents in the consensus formulary; by including patients who could have received formulary drugs appropriately, 73.7% of all prescription orders were or could have been for formulary drugs. Age, race, and sex of patients had no significant effect on utility of formulary agents. Had the 30 drugs most commonly prescribed in this clinic been in the formulary, 82.6% of all prescription orders would have been covered. This approach to establishing a new formulary and selecting drugs for inclusion is potentially useful.