Spindle cell oncocytoma of the neurohypophysis with metastasis to the sphenoparietal sinus and immunohistochemical negativity for S100 and epithelial membrane antigen (EMA).

We report the case of a 61-year-old male with spindle cell oncocytoma of the hypophysis. On presentation to the Department of Neurosurgery at the German Armed Forces Hospital of Ulm, the patient reported a history of several years of left sixth nerve palsy, right ptosis, increased sensitivity to light, and a bilateral retrobulbar pressure sensation. Pituitary function was normal. A chromophobe non-functioning pituitary adenoma was initially suspected. The diagnosis was established on the basis of examination at a histopathology reference laboratory using immunohistochemistry to identify cell surface markers. During two years of follow-up, there were two clinical recurrences requiring surgery. To our knowledge, this is the 35th documented case of spindle cell oncocytoma of the pituitary gland and the first that was immunohistochemically negative for epithelial membrane antigen (EMA) and S100; and the first that displayed haematogenous metastasis to the right sphenoparietal sinus. The three surgical procedures were associated with massive intraoperative bleeding and thus resulted in subtotal tumor resection. Following surgery for the recurrences, the patient underwent radiotherapy.

Multifocal and hormone-dependent epithelioid hemangioendothelioma with osteolysis of the second cervical vertebral body: report of an unprecedented surgical approach by using autologous bone graft.

We report the case of a 28-year-old female patient who complained of extreme neck pain when giving birth to a child. Magnetic resonance imaging (MRI) of the cervical spine demonstrated an osteolytic lesion at the second cervical vertebral body (C2). In this presentation, we highlight a transoral surgical approach in order to prevent instability of this osteolytic lesion. To the best of our knowledge, this is the first time that such a route of access has been described for this tumor entity. A histopathologic examination led to the diagnosis of epithelioid hemangioendothelioma. During a follow-up period of 33 months, the patient had no complaints.

The addition of chloroquine and bevacizumab to standard radiochemotherapy for recurrent glioblastoma multiforme.

INTRODUCTION: Hypoxia-induced autophagy leads to an increase in vasculogenic-mimicry (VM) and the development of resistance of glioblastoma-cells to bevacizumab (BEV). Chloroquine (HCQ) inhibits autophagy, reduces VM and can thus produce a synergistic effect in anti-angiogenic-therapy by delaying the development of resistance to BEV. PURPOSE: We retrospectively compared the combined addition of HCQ+BEV and adjuvant-radiochemotherapy (aRCT) to aRCT alone for recurrent-glioblastoma (rGBM) in regards of overall survival (OS). METHODS: Between 2006 and 2016, 134 patients underwent neurosurgery for rGBM at our institution. Forty-two patients (Karnofsky-Performance-Score>60%) with primary-glioblastoma underwent repeat-surgery and aRCT for recurrence. Four patients (9.5%) received aRCT+HCQ+BEV. Five patients received aRCT+BEV. RESULTS: In rGBM-patients who were treated with aRCT+HCQ+BEV, median OS was 36.57 months and median post-recurrence-survival (PRS) was 23.92 months while median PRS in the control-group was 9.63 months (p=0.022). In patients who received aRCT+BEV, OS and PRS were 26.83 and 12.97 months, respectively. CONCLUSIONS: Although this study was performed on a small number of highly selected patients, it demonstrates a synergistic effect of HCQ+BEV in the treatment of rGBM which previously could be demonstrated based on experimental data. A significant increase of OS in patients who receive aRCT+HCQ+BEV cannot be ruled out and should be further investigated in randomised-controlled-trials.

Pilot testing of direct and indirect potable water reuse using multi-stage ozone-biofiltration without reverse osmosis.

Pilot testing of direct potable reuse (DPR) using multi-stage ozone and biological filtration as an alternative treatment train without reverse osmosis (RO) was investigated. This study examined four blending ratios of advanced treated reclaimed water from the F. Wayne Hill Water Resources Center (FWH WRC) in Gwinnett County, Georgia, combined with the existing drinking water treatment plant raw water supply, Lake Lanier, for potable water production. Baseline testing with 100 percent (%) Lake Lanier water was initially conducted; followed by testing blends of 15, 25, 50, and 100% reclaimed water from FWH WRC. Finished water quality from the DPR pilot was compared to drinking water standards, and emerging microbial and chemical contaminants were also evaluated. Results were benchmarked against a parallel indirect potable reuse (IPR) pilot receiving 100% of the raw water from Lake Lanier. Finished water quality from the DPR pilot at the 15% blend complied with the United States primary and secondary maximum contaminant levels (MCLs and SMCLs, respectively). However, exceedances of one or more MCLs or SMCLs were observed at higher blends. Importantly, reclaimed water from FWH WRC was of equal or better quality for all microbiological targets tested compared to Lake Lanier, indicating that a DPR scenario could lower acute risks from microbial pathogens compared to current practices. Finished water from the DPR pilot had no detections of microorganisms, even at the 100% FWH WRC effluent blend. Microbiological targets tested included heterotrophic plate counts, total and fecal coliforms, Escherichia coli, somatic and male-specific coliphage, Clostridium perfringens, Enterococci, Legionella, Cryptosporidium, and Giardia. There were water quality challenges, primarily associated with nitrate originating from incomplete denitrification and bromate formation from ozonation at the FWH WRC. These challenges highlight the importance of upstream process monitoring and control at the advanced wastewater treatment facility if DPR is considered. This research demonstrated that ozone with biological filtration could achieve potable water quality criteria, without the use of RO, in cases where nitrate is below the MCL of 10 mg nitrogen per liter and total dissolved solids are below the SMCL of 500 mg per liter.

Spine surgery in the International Security Assistance Force Role 3 combat support hospital in Mazar-e-Sharif, northern Afghanistan, 2007-2014.

OBJECTIVESince 2007, a continuous neurosurgery emergency service has been available in the International Security Assistance Force (ISAF) field hospital in Mazar-e-Sharif (MeS), Afghanistan. The object of this study was to assess the number and range of surgical procedures performed on the spine in the period from 2007 to 2014.METHODSThis is a retrospective analysis of the annual neurosurgical caseload statistics from July 2007 to October 2014 (92 months). The distribution of surgical urgency (emergency, delayed urgency, or elective), patient origin (ISAF, Afghan National Army, or civilian population), and underlying causes of diseases and injuries (penetrating injury, blunt injury/fracture, or degenerative disease) was analyzed. The range and pattern of diagnoses in the neurosurgical outpatient department from 2012 and 2013 were also evaluated.RESULTSA total of 341 patients underwent neurosurgical operations in the period from July 2007 to October 2014. One hundred eighty-eight (55.1%) of the 341 procedures were performed on the spine, and the majority of these surgeries were performed for degenerative diseases (127/188; 67.6%). The proportion of spinal fractures and penetrating injuries (61/188; 32.4%) increased over the study period. These spinal trauma diagnoses accounted for 80% of the cases in which patients had to undergo operations within 12 hours of presentation (n = 70 cases). Spinal surgeries were performed as an emergency in 19.8% of cases, whereas 17.3% of surgeries had delayed urgency and 62.9% were elective procedures. Of the 1026 outpatient consultations documented, 82% were related to spinal issues.CONCLUSIONSCompared to the published numbers of cases from neurosurgery units in the rest of the ISAF area, the field hospital in MeS had a considerably lower number of operations. In addition, MeS had the highest rates of both elective neurosurgical operations and Afghan civilian patients. In comparison with the field hospital in MeS, none of the other ISAF field hospitals showed such a strong concentration of degenerative spinal conditions in their surgical spectrum. Nevertheless, the changing pattern of spine-related diagnoses and surgical therapies in the current conflict represents a challenge for future training and material planning in comparable missions.

Primary Amelanotic CNS Melanoma: Case Report and Literature Review.

Primary malignant melanomas of the central nervous system (CNS) are rarely seen entities in the clinical routine. Primary amelanotic melanomas are even rarer. In our literature review, we found only six case reports of primary amelanotic CNS melanomas. Our case report describes the course of a 71-year-old man with a primary amelanotic CNS melanoma with secondary spread to the spine.

[Clinical and Radiological Results after Anterior Cervical Corpectomy with Cage Fusion - a Retrospective Comparison of PEEK vs. Titanium Cages]. / Implantatassoziierte Komplikationen sowie klinischer und radiologischer Verlauf nach anteriorer zervikaler Korpektomie und Cage-Fusion ­ retrospektiver Vergleich von PEEK- gegen Titan-Cages.

Background Anterior cervical corpectomy and fusion (ACCF) has become a standard procedure for patients with spondylotic myelopathy due to multisegmental stenosis of the cervical canal. Beside the fusion technique using autogenous bone grafts, synthetic cages have been increasingly used in recent years. Published information on the clinical and radiological results of different cage materials for ACCF is still limited. The study presented here is the largest series to date reporting clinical and radiological outcomes and complication rates after one- to three-level ACCF using structural polyetheretherketone (PEEK) or titanium cages augmented by anterior plate-screw osteosynthesis. Materials and Methods Retrospective comparative study on 126 patients after cage ACCF using modular PEEK (n = 101) or distractable titanium (n = 25) cages with a minimum follow-up of 6 months. The numbers of hardware failures and implant-related surgical revisions were determined. The rate of subsidence and fusion and the course of lordotic alignment (segmental and regional Cobb's angles) were analysed. Neck Disability Index (NDI) and European Myelopathy Score (EMS) were assessed. Results Significantly greater number of screw and cage complications were detected in the titanium cage group (36 vs. 7.9 % and 64 vs. 36.6 %, respectively). Non-significant trend to a higher rate of implant related revision rate in the titanium cage group (16 vs. 2.97 %). Significantly greater rate of grade I or II fusion in the PEEK cage group after 6 months (82 vs. 52 %). NDI, EMS and lordotic alignment improved significantly in both groups. There were neither significant differences between the two groups nor significant correlations between these clinico-radiological parameters and the cage material. Partial correlations performed with control of parameters showing inhomogenous distribution (patient age, fusion distance, rate of multilevel corpectomy and the rate of intraoperative segmental overdistraction) showed no significant correlations for any of the clinical or radiological outcome parameters and the complications or revisions to the cage material. Conclusion Cages are a safe and effective alternative to autogenous bone graft for ACCF. A significant improvement in clinical and radiological parameters can be achieved with both titanium and PEEK implants. Significant differences between the two cage material groups or significant correlations of clinico-radiological outcome and cage material were not proven. Moreover there is no evidence in the literature for clinical advantages of one special cage material, to date. Therefore further prospective randomised evaluation of different fusion techniques in ACCF is still necessary.

Pediatric Neurosurgical Care in a German Field Hospital in Afghanistan.

Background and Study Objectives Children are commonly found among the injured in war settings. Prognosis often depends on the presence of brain injury. Not all neurosurgery departments of German Armed Forces hospitals, however, have experience in the care of children with neurosurgical conditions. Against this background, we assessed the group of pediatric neurosurgical patients in a German (Role 3) field hospital in Mazar-e-Sharif, Afghanistan. Patients/Materials and Methods We analyzed the operative logbooks from January 1, 2008, to December 31, 2013, to assess the number of neurosurgical procedures that were performed on children (< 18 years of age) at the field hospital of Mazar-e-Sharif. Results During the study period, 327 neurosurgical procedures were performed at the German field hospital. Of these, 29 (9%) were performed on children. The mean age of the pediatric patients (7 girls and 22 boys) was 11.7 years (median age: 12 years; range: 5-17 years). Only three procedures were performed for conditions other than trauma. Pediatric patients accounted for almost 10% of all patients who underwent neurosurgery during a recent military deployment in Mazar-e-Sharif. This percentage is similar to those reported by other nations. These findings show that a considerable number of children underwent neurosurgical treatment. Conclusions Military planners should be aware that Role 3 medical treatment facilities must provide care for pediatric emergencies and must therefore be staffed and equipped accordingly. For military hospitals at home, this means that the management of pediatric patients is an opportunity for medical personnel to receive important pediatric training that enables them to provide care to children in deployed medical facilities.

Survey on Current Postnatal Surgical Management of Myelomeningocele in Germany.

Background and Study Aims Although postnatal surgery can be regarded as the standard of care for open myelomeningocele (MMC), there is no uniform treatment for this condition in Germany. This study assessed the current situation regarding the management of open MMC, a first and essential step toward the development of standards of practice. Patients and Methods In the second half of 2009, we had sent standardized questionnaires to 139 neurosurgery departments and 73 pediatric surgery departments (number of returned questionnaires: 98 and 62, respectively) to identify the principles of MMC management. Newborns with open MMC are treated in 57 of the neurosurgery departments and in 18 of the pediatric surgery departments. Results Overall, 41 of the 57 neurosurgery departments and 16 of the 18 pediatric surgery departments providing care for newborns with MMC perform MMC closure within 24 hours of delivery. In 52 neurosurgery departments and 15 pediatric surgery departments, infants with spina bifida are delivered by planned cesarean section. The diagnostic investigations performed between the time of caesarean delivery and plastic surgical closure vary from none to magnetic resonance imaging of the spine. The criteria underlying the placement of shunts and the time to plastic surgical closure are highly variable. Conclusions The type of treatment that infants with open MMC receive in Germany differs from institution to institution. Clear and consistent guidelines must be established using an interdisciplinary approach to improve treatment and standardize the care provided by surgical specialists for infants with MMC.

Telemetric Intracranial Pressure Measurement: A Graphical Approach to Data Analysis.

PURPOSE: In recent years, radiofrequency identification has been used for the continuous measurement of intracranial pressure (ICP) in patients with a cerebrospinal fluid (CSF) shunt for hydrocephalus . Unlike ICP monitoring in an inpatient setting, measurements in mobile patients outside the hospital provide ICP data that take into account the everyday activities of each individual patient. Common methods of ICP monitoring and analysis cannot be used for those patients. In addition, ICP measurements in mobile patients require considerably longer observation times than in-hospital monitoring. For this reason, ICP measurements over a period of 7 to 10 days must be analyzed effectively and efficiently. METHODS: A possible approach is to analyze ICP data graphically. Pathologic changes can be expected to be associated with specific patterns that can be detected graphically (e.g., Lundberg A waves). Patients without pathologic ICP values and without intracranial pathologies usually show an approximately normal distribution of ICP data. By contrast, patients with pathologic ICP values are likely to show major deviations from a normal distribution such as changes in minimum and maximum values and multimodal distributions. Against this background, we present a new graphical method for detecting pathologic conditions. This novel method is based on the distribution of ICP data that is assessed using GNU R, a free software package for statistical computing and graphics. RESULTS: A left-skewed distribution indicates CSF shunt overdrainage and a right-skewed distribution suggests CSF shunt underdrainage. In addition, an additive analysis of the number of physiologic ICP values can be helpful in detecting possible causes of CSF shunt overdrainage or underdrainage. The approach presented here shows that patients with hydrocephalus objectively benefited from ICP-guided adjustments of the opening pressure of a shunt valve or the insertion of a valve. This objective improvement was confirmed by the patients' subjective perception of well-being. CONCLUSIONS: Further investigations should be performed to examine the influence of multimodal ICP distributions and to assess how data analysis is affected by a drift that can occur when a sensor has been in place for an extended period of time.

A survey on current practice in the neurosurgical management of preterm infants with posthemorrhagic hydrocephalus in Germany.

BACKGROUND AND STUDY AIMS: Different approaches to the management of preterm infants with posthemorrhagic hydrocephalus (PHH) are described in the literature. Likewise, neurosurgical and pediatric surgical departments in German hospitals use different methods to treat these patients. The aim of this study was therefore to assess the current situation regarding the management of PHH, which is a first and essential step toward the development of standards of practice. PATIENTS AND METHODS: In the second half of 2009, we sent standardized questionnaires to 139 neurosurgical departments (number of returned questionnaires: 98) and 73 pediatric surgical departments (returned questionnaires: 62) to identify the principles of PHH management. Preterm infants with PHH are treated in 61 of the neurosurgical and in 20 of the pediatric surgical departments. RESULTS: 43 of the 61 neurosurgical departments and 17 of the 20 pediatric surgical departments providing care for preterm infants with PHH treat less than 10 preterm infants with PHH per year. Reservoir placement is performed as the initial treatment in 48 neurosurgical and in 14 pediatric surgical departments.The criteria for the placement of ventriculoperitoneal shunts and the implantation procedure itself are highly variable. Moreover, the percentage of children who require a CSF shunt after initial treatment for PHH ranges between 5 and 95%. CONCLUSIONS: In Germany, the type of treatment of infants with PHH differs from institution to institution. Clear and consistent guidelines must be established in an interdisciplinary approach to improve and better coordinate the management of infants with PPH.

Intraoperative image guidance in neurosurgery: development, current indications, and future trends.

Introduction. As minimally invasive surgery becomes the standard of care in neurosurgery, it is imperative that surgeons become skilled in the use of image-guided techniques. The development of image-guided neurosurgery represents a substantial improvement in the microsurgical treatment of tumors, vascular malformations, and other intracranial lesions. Objective. There have been numerous advances in neurosurgery which have aided the neurosurgeon to achieve accurate removal of pathological tissue with minimal disruption of surrounding healthy neuronal matter including the development of microsurgical, endoscopic, and endovascular techniques. Neuronavigation systems and intraoperative imaging should improve success in cranial neurosurgery. Additional functional imaging modalities such as PET, SPECT, DTI (for fiber tracking), and fMRI can now be used in order to reduce neurological deficits resulting from surgery; however the positive long-term effect remains questionable for many indications. Method. PubMed database search using the search term "image guided neurosurgery." More than 1400 articles were published during the last 25 years. The abstracts were scanned for prospective comparative trials. Results and Conclusion. 14 comparative trials are published. To date significant data amount show advantages in intraoperative accuracy influencing the perioperative morbidity and long-term outcome only for cerebral glioma surgery.

Three years of neurosurgical experience in a multinational field hospital in northern Afghanistan.

BACKGROUND: Since July 2007, neurosurgical services have been continuously available in a multinational Role 3 field hospital in Mazar-e-Sharif (MeS), Afghanistan. In this paper, we analyse a 3-year neurosurgical caseload experience. METHODS: We retrospectively analysed the neurosurgical caseload at a Role 3 medical treatment facility in northern Afghanistan between October 2007 and October 2010. The cases were divided into acute, urgent and elective procedures and into cranial, spinal, peripheral nerve and miscellaneous surgeries. RESULTS: A total of 190 surgeries were performed. Of these, 50 operations (26.3%) were acute procedures that were conducted to save lives or preserve neurological function. In addition, operations included 47 urgent (24.7%) and 93 elective (49%) procedures. There were 58 cranial surgeries (30.5%), 113 spinal surgeries (59.5%), 11 peripheral nerve surgeries (5.8%), and 8 miscellaneous surgeries (4.2%). Surgical treatment was provided to 13 International Security Assistance Force (ISAF) soldiers (6.8%), 22 members of the Afghan National Security Forces (11.6%), and 155 Afghan civilians (81.6%). CONCLUSIONS: The primary mission of the field hospital is to provide sick, injured or wounded ISAF personnel with medical and surgical care, the outcome of which must correspond to standards prevailing in Germany. Only a very small number of neurosurgical operations performed in MeS met the criteria established by this mission statement and by the modern principles of damage-control wartime surgery. This is completely different from the experience reported by other ISAF nations in eastern and southern Afghanistan.

Intraoperative three-dimensional imaging in selective decompression for lumbar spinal stenosis: a useful tool in theory but also in everyday practice?

Background. We conducted a pilot study to investigate the value of an Iso-C3D imaging system in determining the extent of decompression of lumbar spinal stenosis during surgery. We now address the question whether this imaging has become a routine tool. Material and Methods. Ten patients who underwent unilateral decompression for lumbar spinal stenosis were intraoperatively examined using the Iso-C3D imaging system. Four years after this study, we investigated whether this intraoperative imaging modality is still being used. Results. Evaluable images were intraoperatively obtained for all patients. In two cases, the surgical procedure was changed on the basis of the images. Myelography did not provide any additional information. In the four years following the study, this intraoperative imaging technique has not been used again. Conclusion. Intraoperative imaging using the Iso-C3D system provides additional safety. It, however, has not become established as a routine procedure.

Standard and cardiac-gated phase-contrast magnetic resonance imaging in the clinical course of patients with Chiari malformation Type I.

OBJECT: The causal treatment of Chiari malformation Type I (CM-I) consists of removing the obstruction of CSF flow at the level of the foramen magnum. Cerebrospinal fluid flow can be visualized using dynamic phase-contrast MR imaging. Because there is only a paucity of studies evaluating CSF dynamics in the region of the spinal canal on the basis of preoperative and postoperative measurements, the authors investigated the clinical usefulness of cardiacgated phase-contrast MR imaging in patients with CM-I. METHODS: Ninety patients with CM-I underwent preoperative MR imaging of CSF pulsation. Syringomyelia was present in 59 patients and absent in 31 patients. Phase-contrast MR imaging of the entire CNS was used to investigate 22 patients with CM-I before surgery and after a mean postoperative period of 12 months (median 12 months, range 3-33 months). In addition to the dynamic studies, absolute flow velocities, the extension of the syrinx, and tonsillar descent were also measured. RESULTS: The changes in pulsation were highly significant in the region of the (enlarged) cistern (p = 0.0005). Maximum and minimum velocities (the pulsation amplitude) increased considerably in the region where the syrinx was largest in diameter. The changes of pulsation in these patients were significant in the subarachnoid space in all spinal segments but not in the syrinx itself and in the central canal. CONCLUSIONS: The demonstration of CSF flow pulsation can contribute to assessments of surgical outcomes. The results presented here, however, raise doubts about current theories on the pathogenesis of syringomyelia.

Noninvasive intracranial pressure measurement using infrasonic emissions from the tympanic membrane.

OBJECTIVE: We investigated whether ICP can be assessed by measuring infrasonic emissions from the tympanic membrane. METHODS: An increase in ICP was induced in 22 patients with implanted ICP pressure sensors. ICP waveforms that were obtained invasively and continuously were compared with infrasonic emission waveforms. In addition, the noninvasive method was used in a control group of 14 healthy subjects. RESULTS: In a total of 83 measurements, the changes in ICP that were observed in response to different types of stimulation were detected in the waveforms obtained noninvasively as well as in those acquired invasively. Low ICP was associated with an initial high peak and further peaks with smaller amplitudes. High ICP was associated with a marked decrease in the number of peaks and in the difference between the amplitudes of the initial and last peaks. The assessment of infrasonic emissions, however, does not yet enable us to provide exact figures. CONCLUSION: It is conceivable that the assessment of infrasonic emissions will become suitable both as a screening tool and for the continuous monitoring of ICP in an intensive care environment.

Treatment of unresectable skull base meningiomas with somatostatin analogs.

OBJECT: The standard surgical treatment for meningiomas is total resection, but the complete removal of skull base meningiomas can be difficult for several reasons. Thus, the management of certain meningiomas of the skull base--for example, those involving basal vessels and cranial nerves--remains a challenge. In recent reports it has been suggested that somatostatin (SST) administration can cause growth inhibition of unresectable and recurrent meningiomas. The application of SST and its analogs is not routinely integrated into standard treatment strategies for meningiomas, and clinical studies proving growth-inhibiting effects do not exist. The authors report on their experience using octreotide in patients with recurrent or unresectable meningiomas of the skull base. METHODS: Between January 1996 and December 2010, 13 patients harboring a progressive residual meningioma (as indicated by MR imaging criteria) following operative therapy were treated with a monthly injection of the SST analog octreotide (Sandostatin LAR [long-acting repeatable] 30 mg, Novartis). Eight of 13 patients had a meningioma of the skull base and were analyzed in the present study. Postoperative tumor enlargement was documented in all patients on MR images obtained before the initiation of SST therapy. All tumors were benign. No patient received radiation or chemotherapy before treatment with SST. The growth of residual tumor was monitored by MR imaging every 12 months. RESULTS: Three of the 8 patients had undergone surgical treatment once; 3, 2 times; and 2, 3 times. The mean time after the last meningioma operation (before starting SST treatment) and tumor enlargement as indicated by MR imaging criteria was 24 months. A total of 643 monthly cycles of Sandostatin LAR were administered. Five of the 8 patients were on SST continuously and stabilized disease was documented on MR images obtained in these patients during treatment (median 115 months, range 48-180 months). Three of the 8 patients interrupted treatment: after 60 months in 1 case because of tumor progression, after 36 months in 1 case because of side effects, and after 36 months in 1 case because the health insurance company denied cost absorption. CONCLUSIONS: Although no case of tumor regression was detected on MR imaging, the study results indicated that SST analogs can arrest the progression of unresectable or recurrent benign meningiomas of the skull base in some patients. It remains to be determined whether a controlled prospective clinical trial would be useful.

Arachnoscopy: a special application of spinal intradural endoscopy.

OBJECT: The microsurgical removal of obstructions to CSF flow is the treatment of choice in the surgical management of intradural arachnoid cysts. Cardiac-gated phase-contrast MR imaging is an effective tool for the primary diagnosis and localization of arachnoid cysts. Microsurgery, however, does not lend itself to assessments of further adhesions beyond the borders of the exposed area. The use of a thin endoscope allows surgeons to assess intraoperatively whether the exposure is wide enough. METHODS: Between 2006 and 2010, a single neurosurgeon performed 31 consecutive microsurgical procedures with endoscopic assistance in 28 patients with spinal arachnoid adhesions. A MurphyScope endoscope was used for this purpose. The CSF flow was studied before and after surgery in all patients by using phase-contrast MR imaging in the region of the craniocervical junction, the cervical spine, the thoracic spine, and the lumbar spine. RESULTS: In all 31 procedures, CSF flow obstructions were detected at the level identified by phase-contrast MR imaging. In 29 procedures, image quality was sufficient for an inspection of the adjacent subarachnoid space. In 6 cases, the surgeon detected further adhesions that obstructed CSF flow in the adjacent subarachnoid space that were not visualized with the microscope. In all cases, these adhesions were identified and removed during microsurgery. CONCLUSIONS: Arachnoscopy is a helpful adjunct to microsurgery and can be performed safely and easily. It allows the surgeon to detect further adhesions in the subarachnoid space that would remain undetected by microscopy alone.

German military neurosurgery at home and abroad.

For many years, the experience of neurosurgeons from the German Armed Forces was limited to the peacetime care of patients in Germany. In 1995, German military neurosurgeons were deployed abroad for the first time. Since the beginning of the International Security Assistance Force mission, there has been a rapidly increasing number of opportunities for military neurosurgeons to broaden their experience during deployments abroad. Since the first deployment of a neurosurgeon to the German field hospital in Mazar-e-Sharif, Afghanistan, a total of 140 neurosurgical procedures have been performed there. Sixty-four surgeries were performed for cranial or spinal neurotrauma management. During the entire period, only 10 International Security Assistance Force members required acute or urgent neurosurgical interventions. The majority of neurosurgical procedures were performed in Afghan patients who received acute and elective treatment whenever the necessary infrastructure was available in the field hospital. Fifteen patients from the Afghan National Army and Police and 115 local patients underwent neurosurgery. Sixty-two procedures were carried out under acute or urgent conditions, and 78 operations were elective.