Complications following anterior cervical spine surgery for disc diseases: an analysis of ten years experience.

The purpose of this study is to define, analyse and discuss the incidence and severity of the complications associated with anterior cervical spine surgery for degenerative disc diseases. The results and the management of complications of anterior spine surgery are discussed in relation to numerous previous published reports: precise knowledge of all potential accidents and pitfalls related to the surgical approaches and of their aetiology may contribute to preventing failures. The most common complication was a recurrent laryngeal nerve injury that developed in 7.9% of the cases. Dysphagia occurred in 5.6%, hoarseness in 5.2%, transient sore throat in 4.8%, worsening of pre-existing myelopathy in 3%, graft extrusion in 1.7%; root injury, haematoma, and wound infection developed in 0.87%. There was one case of oesophageal injury (0.43%) and there were no deaths related to the surgical approach. The rate of complications in our series has been reduced in the past years by 1) better patients selection: all of the patients in fact had previously received conservative treatment for at least four weeks; 2) more care in correct positioning of the patient during the operation; 3) meticolous removal of all harmful structures.

Spinal chondroma of the lumbar tract: case report.

BACKGROUND: Cartilage-forming tumors are benign cartilaginous tumors that rarely affect the spinal canal: they account for 2% of all spinal tumors and 2.6% of all benign bone tumors. Pathologically, they may be classified as chondromas, osteochondromas, chondroblastomas, and chondromyxoid fibromas. This oncotype may remain asymptomatic (it is confined within the vertebral structure) or may present as a hard paravertebral swelling (it invades the paravertebral structures) or more rarely, with a slowly-developing neurologic syndrome (it extends into the vertebral canal). METHODS: Thirty-one cases have been reported (including our case) of benign cartilage-forming tumors localized in the lumbar column. Only three cases of chondroma of the lumbar spine presented with lumbar radicular pain. We report a fourth case and review clinical and radiologic characteristics of these lesions. RESULTS: Eleven out of the 31 cases were diagnosed as chondromas, 17 as osteochondromas, while in three cases the histopathologic diagnosis was not reported. Seventeen cases originated from the neural arch, seven from the vertebral body, two from the spinous process, and in five cases the exact localization was not reported. This tumor is more frequent in males (21 cases out of 31), than in females (five cases); in five cases the sex was not reported. Mean duration of symptoms was 23 +/- 5.1 months (range: 1-96); chondromas have a short clinical history before diagnosis (13.8 +/- 3.4 months) compared to osteochondromas (28.6 +/- 7.6). Clinical presentation with local swelling is reported in 10 cases, in 10 cases local pain without radicular irradiation, in six cases lumbar pain with sciatica, in two cases signs and symptoms of cord compression, one case of cauda syndrome, while in four cases no clinical details are reported. Among the six cases presenting with sciatica, four were chondromas (in all cases the L4 level was involved), and one osteochondroma, while in one case the histopathologic diagnosis was not reported. CONCLUSION: Computed tomography is important and indispensable for preoperative diagnosis, giving a precise indication of tumor extent and location and its relationship to the adjacent structures; while MRI is helpful in detecting patterns related to histologic malignancy. It is important to examine the whole tumor histologically because it is known that there may be small areas that show signs of malignancy; thus is more likely in chondromas than osteochondromas.

Anterior cervical discectomy: an analysis on clinical long-term results in 153 cases.

During the last three decades, the anterior approach to the cervical spine with interbody fusion has been increasingly preferred in the operative treatment of herniated cervical disc. Most studies on surgical procedure without interbody fusion are retrospective and reported that the bone graft is not important for the success of this technique. Between 1983 and 1993, 153 patients underwent surgery for the treatment of cervical degenerative disc disease: in 139 cases the technique without fusion was applied. This retrospective study analyze clinical and radiological parameters in order to verify any possible prognostic factor. 108 patients with radiculopathy and 31 patients with myelopathy were followed up clinically for at least 12 months up to 10 years. An excellent or good long-term result was achieved in 90.9% of patients with radiculopathy and 58.1% of those with myelopathy. The age of the patients, the duration of symptoms before diagnosis and the pathogenesis of disc herniation did not represent significant parameters influencing the outcome of patients. The results of the present study show that anterior discectomy without fusion lead to good clinical long-term results, either in patients with pure radicular syndrome, or in cases with myelopathy. The presentation with pure radicular signs is the most important factor in predicting a good overall outcome.

Endothelin and aneurysmal subarachnoid haemorrhage: a study of subarachnoid cisternal cerebrospinal fluid.

Endothelin (ET) is considered one of the most potent vasoconstrictor polypeptides; several experimental studies have suggested its possible role in the pathogenesis of arterial vasospasm after subarachnoid haemorrhage (SAH). Previously reported data on plasma and CSF levels of endothelin in patients with a diagnosis of SAH have been controversial. Cisternal endothelin CSF levels and the possibility that they could be related to vasospasm and other clinical patterns of SAH were investigated. CSF samples were obtained from 55 patients admitted after angiographic diagnosis of intracranial aneurysm. Levels of ET-1 and ET-3 were measured through radio-immunoassay technique. Twelve patients who had operations for unruptured aneurysms were considered control cases; 43 patients with SAH were classified according to: Hunt and Hess grading at admission, vasospasm grading, CT classification and timing of surgery. In all 55 patients ET-1 was measured, while positive levels of ET-3 were found only in 17 cases of 48. No linear correlation was found between cisternal CSF ET-1 levels when considering time of surgery, CT classification, Hunt and Hess grading at admission, and vasospasm grading. The results of ET-3 assay should be considered with great caution because of the low percentage of positive cases. Cisternal CSF levels of ET-1 and ET-3 are not directly related to the occurrence of arterial vasospasm after the aneurysm rupture, or to other major clinical patterns of SAH; however, ET-1 expression occurs either in paraphysiological (unruptured aneurysm) or in pathological conditions (SAH). It is suggested that ET may potentiate, or may be potentiated by, other factors playing a consistent pathophysiological role in the development of vasospasm.

Antioxidant enzymatic activities after experimental subarachnoid hemorrhage in rats.

Lipid peroxidation has been hypotesized as one of possible factors involved in the pathogenesis of neuronal damage and delayed vasospasm after subarachnoid hemorrhage. In the brain there are anti-oxidant enzymatic systems which act as scavengers of superoxides and free radicals. In the present study the pattern of enzymatic anti-oxidant activities (Cu-Zn and Mn superoxide dismutase, and glutathione peroxidase) was investigated in an experimental model of subarachnoid hemorrhage in the rat in order to verify whether the hemorrhagic insult may be responsible for an impairment of such anti-oxidant systems. Enzymatic activities were assayed in three different rat brain areas (cerebral cortex, hippocampus and brain stem) of sham-operated and at 30 min, 1, 6 and 48 h after subarachnoid hemorrhage induction. After the hemorrhage induction the Cu-Zn superoxide dismutase activity in cerebral cortex was significantly reduced at all the set times (p < .05), while Mn-superoxide dismutase activity was significantly decreased since 1 h (p < .05) until 48 h (p < .05). Glutathione peroxidase activity was significantly reduced only in the late phase (48 h) of subarachnoid hemorrhage (p < .01). In the hippocampus, all enzymatic activities were significantly reduced in the late phase. In the brain stem Cu-Zn superoxide dismutase was significantly impaired at 1 and 6 h (p < .05) after subarachnoid hemorrhage induction, while in the late phase (48 h) reached the control value. The mitochondrial Mn-superoxide dismutase was significantly reduced since 1 h (p < .05) until 48 h (p < .02) after subarachnoid hemorrhage.(ABSTRACT TRUNCATED AT 250 WORDS)

[State of the art in the treatment of cerebral gliomas]. / Stato dell'arte sul trattamento dei gliomi cerebrali.

Current knowledge on the multiple aspects of intracranial glioma is presented. In particular, after illustrating the most recent epidemiological data and the latest acquisitions in the biological and biochemical fields, the present status of multidisciplinary treatment (surgery, radiotherapy, and chemo-immunotherapy) of these neoplasia is described.

Effects of nicardipine treatment on Na(+)-K+ ATPase and lipid peroxidation after experimental subarachnoid haemorrhage.

The calcium theory of neuronal damage has been recently adapted to subarachnoid haemorrhage (SAH). It is proposed that haemorrhagic insult to the brain causes free radical-mediated destructive reactions of membrane phospholipids, and the consequent decrease of phospholipid-dependent enzymatic activities, such as Na(+)-K+ ATPase. In the present study we have studied the effects of Nicardipine treatment on lipid peroxidation and Na(+)-K+ ATPase activity after experimental induction of SAH. SAH was induced in anaesthesized rats by slow injection of 0.3 ml of autologous arterial blood into the cisterna magna. We assessed the extent of lipid peroxidation by measuring the level of thiobarbituric acid reactive substances (TBARS) and Na(+)-K+ ATPase activity in 3 different rat brain areas (cerebral cortex, hippocampus and brain stem) of sham-operated (0.3 ml of mock CSF into cisterna magna) and at 1 hour, 6 hours and 48 hours after SAH induction; simultaneously, we investigated the capacity of cerebral lipid peroxidation by measuring the accumulation of TBRAS in homogenates of brain areas incubated under aerobic conditions. Na(+)-K+ ATPase activity decreased in the cerebral cortex at 1 hour and 6 hours and in brain stem at 1 hour after SAH, while the same enzymatic activity did not change in the hippocampus. There was no significant difference in lipid peroxide content between sham-operated and haemorrhagic animals; Nicardipine treatment reduced the TBRAS content and induced the recovery of Na(+)-K+ ATPase activity, exerting a brain protective role against the detrimental effects of the haemorrhage.

Surgical therapy of malignant gliomas.

The authors have presented the current state of surgical therapy of malignant gliomas underlining the advantages and disadvantages of traditional and stereotactic surgery, preparation for surgery, mortality, morbidity, prognostic factors, and complications. Particular attention was placed on cell kinetic studies. Of the methods used in this study we would like to recall those of flow cytometry associated with administration of BUdR and utilization of the monoclonal antibody Ki-67 associated with immunohistochemical techniques.

Idiopathic hydrocephalic dementia in aging brain the neurosurgical approach.

On the basis of our 16 years' experience, we have treated 36 patients by extrathecal shunt for idiopathic normal pressure hydrocephalus. All patients were submitted to clinical evaluation, neuroradiological, and neuropsychological (Mini Mental Test) tests. Seventy-six per cent of patients showed a significant clinical improvement. No change was found in 24% of them, including two patients who died. In a group of 13 patients we measured the level of main neurotransmitter metabolites (MHPG, HVA, 5-HIAA) in order to evaluate the functional status of encephalic monoaminergic system. If care is taken to make a correct diagnosis and give adequate treatment with a shunt, hydrocephalic dementia has a good prognosis.

Postoperative scars and recurrent disk herniation: clinical, neuroradiological, and surgical findings.

Authors present 36 patients with recurrent sciatica or low-back pain after lumbar disk operation. All patients were submitted to clinical and instrumental devices. CT-scan was performed in 36 patients, 12 underwent myelography and 4 EMG. Authors verified reliability of clinical and instrumental devices on the basis of surgical results. We believe that myelo-CT is actually the first choice investigation in the neuroradiological ones. In the near future MRI will take its place in investigating spinal pathology.

Spinal subdural haematoma: a rare complication of lumbar puncture. Case report and review of the literature.

The Authors describe a case of spinal subdural haematoma presenting as a cyst. It ist noted that cerebrospinal fluid parameters were normal, in contrast to what is usually found in similar cases; furthermore, no sensorimotor impairment was seen. Histological examination showed an organised haematoma; that explains why CT scan was not diagnostic in this case. Haematoma is probably due to the rupture of a vein localised between the dura mater layers.

Lumbar canal stenosis: results in 40 patients surgically treated.

Authors present the clinical and neuroradiological characteristics of 40 patients treated for lumbar canal stenosis during a 10 years experience. The usefulness of computed tomography in comparison with myelography and plain X-rays of the spine is stressed. The surgical treatment was wide laminectomy involving one or more levels (two to four) plus an eventual foraminotomy but without discectomy. All patients were followed up and in 85% of cases a reduction of clinical symptoms was observed. Residual symptoms were also present in some of the improved patients, they generally accepted them without great dismay.

Effect of nimodipine on mitochondrial respiration in different rat brain areas after subarachnoid haemorrhage.

The mitochondrial respiration was evaluated in three different rat brain areas (cerebral cortex, hippocampus and brain stem) after experimental subarachnoid haemorrhage (SAH). The haemorrhage was induced by injecting 0.35 ml of autologous arterial blood into cisterna magna. Intravenous administration of Nimodipine (2 micrograms/kg/min for 30 minutes) was started immediately after the haemorrhage induction. At the set time (1 hour after SAH procedure), animals were sacrificed and non-synaptic mitochondria from the above mentioned areas were isolated. The following respiratory parameters were evaluated utilizing glutamate plus malate and succinate plus rotenone as substrates: state 3, state 4, uncoupled state, respiratory control ratio (RCR) and ADP/O ratio. SAH significantly influences respiratory parameters, mainly RCR; the cerebral cortex and brain stem seem to be more sensitive during the acute phase of vasospasm which follows SAH procedure. Nimodipine treatment significantly ameliorates mitochondrial respiratory conditions.

Reliability of clinical examination and computed tomography in the diagnosis of extreme lateral disc herniation.

Twenty-eight cases of extreme lateral and foraminal disc herniation diagnosed by CT are reported. All cases have been surgically verified. In four cases (14%) CT diagnosis failed. The clinical pattern in these cases was not very different from that of typical disc herniation. The reliability of clinical diagnosis is 71%. EMG is seldom diagnostic. Myelography is uniformly of no value as a diagnostic measure.

Spinal epidural hematoma without vertebral fracture or dislocation. Report of two cases and review of the literature.

Authors present 2 cases of spinal epidural hematoma without vertebral fracture or dislocation and review the literature. 169 fully described cases were found in literature and have been analyzed. Data confirm our opinion that the results of an early diagnosis is a better prognosis. The severity of preoperative neurological status is another important factor for the post-operative recovery, any way the absence of neurological function before the operation is not necessarily leading to a poor prognosis. Prognosis is usually poor when after the removal of the hematoma the dural pulsation is absent.

Nitrosourea derivatives-induced pulmonary toxicity in patients treated for malignant brain tumors. Early subclinical detection and its prevention.

Nitrosourea derivatives, such as BCNU and CCNU, are considered useful chemotherapeutic agents in malignant brain tumors combined therapy. Pulmonary toxicity is one of the major side effects demonstrated both in experimental animal models and in human autoptic findings. Pulmonary fibrosis is the end point of progressive functional disorder of respiratory mechanism and alveolo-capillary gas exchanges. Authors present the results of a randomized, double-blind trial of 40 patients previously treated with surgery and radiotherapy and who subsequently underwent BCNU therapy for primary intracranial glioma. Patients underwent functional respiratory examinations at each chemotherapy course interval. Twenty patients received ambroxol (120 mg/day) for 40 days after chemotherapy course. Control patients received placebo with the same schedule and showed a significant reduction of pulmonary functional parameters (DLCO, MMEF, MEF 25%), whereas in the treated group there is no significant variation of these functional parameters. The mechanism of ambroxol is commonly related to the surfactant synthesis enhancement and to the action on bronchiolar pathways.

Complications following surgery for severe head injury.

The number of patients who survive, after severe head injuries, is becoming more and more consistent due to the remarkable progress made in intensive care and rehabilitation units. The aim of this study is to identify, in addition to direct structural damage, medical and neurological problems and describe their frequency within a group of patients with severe head injuries. Neurologic, metabolic, gastrointestinal, genitourinary, respiratory, cardiovascular, cutaneous and endocrinologic problems were more frequently found. All these problems, which were identified during the first month after head injury, are discussed regarding their clinical significance, therapeutic approach, and morbidity.

[Supra- and subtentorial "hourglass" dermoid. Clinical case and review of the literature]. / Dermoide "a clessidra" sopra e sottotentoriale. Caso clinico e revisione della letteratura.

Authors report a case of 58 year-old woman suffering from a "clepsydra" shaped dermoid tumor spreading from the middle cranial fossa to the left posterior cranial fossa. The diagnostic importance of computed cysternotomography and the minor diagnostic value of other techniques such as angiography and pneumoencephalography is emphasized. The clinical picture and the surgical procedure are discussed in relation to a review of data available in the literature.

[Cerebral vasospasm caused by subarachnoid hemorrhage]. / Il vasospasmo cerebrale da emorragia subaracnoidea.

Vasospasm is one of the most frequent complications of subarachnoid hemorrhage (SAH) and causes high mortality rates and serious neurologic deficits, resulting in invalidity. Diagnosis is based on precise clinical criteria (onset between the 3rd and the 8th day after the SAH) and is confirmed by angiographic examination. The etiology certainly involves many factors, though the identification of the primary cause (conductive to morpho-structural alterations of the artery walls) seems to be troublesome. Experimental evidence indicates that the basis of the reactions which cause the onset of the vasospasm lies in the blood which pools in the subarachnoid zone. The authors summarize the main pathogenetic theories, especially as far as the initial biochemical sequence is concerned. Among the numerous classes of substances involved in the genesis of vasospasms, a relevant role is played by oxyhaemoglobin, free radicals, lipidic peroxides and by the metabolites of arachidonic acid. The main purpose of vasospasm treatment is the possibility to eliminate and prevent ischemic complications. Early surgical exclusion of the aneurysm causing the bleeding allows for the removal of peri-aneurysmatic blood clots. Pharmacological treatment employs numerous classes of substances: among these calcium antagonists presently appear to give satisfactory results.

[Comparison of clinical examination, electromyography, myelography, computerized tomography and surgical findings in lumbar disc hernias]. / Confronto tra esame clinico, elettromiografia, saccoradicolografia, tomografia computerizzata e riscontro operatorio nelle ernie del disco lombare.

The authors report 152 cases of patients with suspected herniated lumbar disk, operated on by traditional surgical approach. Thirteen of 152 patients underwent exploratory surgery at two vertebral spaces as a result of their neuroradiological examinations. All patients were examined clinically before of instrumental devices. CT-scan was performed on 113 patients, 62 underwent myelography and 36 electromyography. The authors verified reliability of clinical and instrumental devices on the basis of surgical results. Clinical examination was reliable in 83% of cases, electromyography in 78%, myelography in 83% and CT-scan in 87%. The percentage of false positive was 11% for the clinical examination, 9% for CT-scan, 8% for myelography and 11% for electromyography. The percentage of false negative was 6% for the clinical examination, 4% for CT-scan, 9% for myelography, and 11% for electromyography. The authors conclude that the CT-scan is the most reliable method of examination. This is even truer when dealing with extreme lateral disk herniation.