Extensive cerebral invasion of a basal cell carcinoma of the scalp.

Basal cell carcinomas (BCC) are the most common cutaneous malignant neoplasms affecting fair-skinned human beings. They may progressively enlarge and spread by peripheral extension. Intracranial invasion is very rare. A case of a giant BCC of the scalp invading directly into the left hemisphere through the frontal and parietal lobe and meninges is presented. Brain invasion along Virchow-Robin's spaces is demonstrated histopathologically. A review of literature failed to disclose a previous report of similar extensive and fatal cerebral invasion from a basal cell carcinoma of the scalp.

Non-invasive measurement of intracranial pressure changes by otoacoustic emissions (OAEs)--a report of preliminary data.

Up to now changes of intracranial pressure can only be objectively assessed by invasive measurement tools e.g. epidural transducers or intraventricular or intraparenchymatous catheters. Changes of intracranial pressure (ICP) are known to influence the inner ear since the subarachnoid space is linked to the perilymphatic space of the inner ear via the cochlear aquaeduct. A new method for assessing cochlear disorders is based on otoacoustic emissions (OAE) which are generated by the outer hair cells (OHCs) of the inner ear. The aim of the present study was to find out whether changes of intracranial pressure can be monitored by spontaneous otoacoustic emissions (SOAEs), transient evoked otoacoustic emissions (TEOAEs) and distortionproduct otoacoustic emissions (DPOAEs). SOAEs, TEOAEs and DPOAEs were measured in 12 young normally hearing subjects (volunteer group) in different body postures (horizontal, -30 degrees and +30 degrees supine position). In 5 patients undergoing continuous intraventricular pressure monitoring for the assessment of normal pressure hydrocephalus (NPH), DPOAEs were measured simultaneously in different body postures as well (patient group). At an increase of ICP the SOAE-level of the volunteer group decreased by -3.3 dB SPL (sound pressure level) and the TEOAE-level by -2.1 dB SPL. The DPOAEs showed a frequency dependent reduction of its level with maximal changes at the lowest frequency tested (f2 = 1 kHz; -7.9 dB SPL). In the patient group the ICP amounted to 19.2 cm H(2)0 and the DPOAE-level also decreased particularly at lower frequencies (-2.0 dB SPL). In conclusion otoacoustic emissions, particularly DPOAEs, may provide a new clinical tool for non-invasive monitoring of ICP.

[Ependymoma of the thoracic spine. Cervico-brachialgia as the first symptom--a case report]. / Das Ependymom der Brustwirbelsäule. Die Zervikobrachialgie als Erstsymptom--eine Kasuistik.

Most frequently the ependymomas of the central nervous system affect the Conus medullaris and Filum terminale. Ependymomas of the thoracic spine with association of a tumor-caused syringomyelia are extremely rare. The reported 50 years old patient with a thoracic ependymoma realized first symptoms as a shoulder-arm pain caused by the tumor-syrinx. The case report indicates that MRI is the superior imaging modality for primary tumors of the central nervous system. All relevant diagnostic and therapeutic informations derived from the MRI. The article describes the clinical manifestations, the diagnostic way and therapeutic procedure in the problem region thoracic spine.

[Thoracic intervertebral disk displacement: a rare differential diagnosis of segmental irritation--guidelines for use of chiropractic therapy]. / Der thorakale Bandscheibenvorfall: eine seltene Differentialdiagnose der segmentalen Irritation--Richtlinien zur Anwendung von Chirotherapie.

Thoracic disc herniations rarely occur; they vary with respect to the clinical symptomatic and do not always lead to neurological deficit. A patient is being reported on with first symptoms of unspecific back pain. The patient has been frequently treated within 12 months (at regular intervals) exclusively by chiropractic manipulation without a considerable success. It is the objective of this case report that in persistent and therapy resistant back pain without obvious neurological deficite beside native radiographs further diagnostic investigation (MRI) is indicated. Concerning chiropractic manipulations (mobilisation techniques with impulse) this paper recommends testing maneuvers, the consideration of contraindications (structural lesions, neurological deficite) and emphasizes the use of atraumatic manipulation techniques.

Optimized visualization of contrast medium dependent differences in CT/MRI scans by RGB transformation.

OBJECTIVE: In order to be able to assess the contrast medium enhancement of vessels and regions with disturbed blood-brain barrier, the neurosurgeon must mentally perform a subtraction of the corresponding native and contrast-enhanced scans of the CT or MRI. The principle disadvantages of this comparison are the amount of time required and the potential errors which may result from false interpretation. METHODS: The process presented here combines corresponding scans without and with contrast medium offline on a PC. In this process each couple of the black and white scans is assigned to the colour channels of the RGB system (red, green, blue) and transformed to one colour picture of the RGB colour space (additive colour mixture). RESULTS: We demonstrate that contrast medium-dependent changes can be represented in a colour contrast of complementary colours in one single picture. Additionally, the unchanged structures remain in the black and white contrast as they were before. CONCLUSION: Thanks to the optimized visualization of contrast medium dependent differences there are besides saving in time further advantages such as the reduced amount of pictures and an objective representation.

Dorsal extradural lipoma as cause of spinal claudication. Case report and review of the literature.

Extradural spinal lipomas are rare tumorous lesions. "True adult lipomas" have to be histologically differentiated from angiolipomas. The authors describe a case of segmental dorsal lipomas in the lower lumbar spine which led to a clinical apparent spinal claudication. Having reviewed the literature this case is the first ever described. In this case MRI was the diagnostic tool of choice. The tumor could be removed completely via interarcual laminotomy and flavectomy. The clinical outcome was excellent. In differential diagnosis of a spinal claudication this rare cause should be kept in mind when typical osseous changes are absent.

[Postoperative spondylodiscitis as the cause of failed-back syndrome--clinical aspects, diagnosis, therapy]. / Die postoperative Spondylodiscitis als Ursache des Failed-Back-Syndromes--Klinik, Diagnostik, Therapie.

Postoperative lumbar spondylodiscitis can cause a failed back syndrome. With 0.1 to 3% according to the literature it belongs to the rarer complications following lumbar disc surgery. We present the characteristic clinical picture and typical findings (ESR, plain X-rays, MR) with suspected spondylodiscitis on 19 patients (= 0.2% of 9492 operative interventions for lumbar disc prolapse from 1980 to 1990) and show MR tomography to be the most sensitive investigation. Principles of therapy consist of lumbar immobilisation with a light cast orthesis for an average of 12 weeks and additional antibiotic therapy up to two weeks beyond normalisation of ESR. Finally results of therapy are presented with a satisfying outcome in 84.2% of cases.

[Are sacroiliac joint block and insertion tendinosis of the musculus erector trunici too rarely diagnosis as the etiology of failed back syndrome after intervertebral disk operation]. / ISG-Blockierung und Ansatztendinose des Musculus erector trunici als Ursache des Failed-back-Syndroms nach Bandscheibenoperation--zu selten diagnostiziert?

Dysfunction of sacroiliac joint and tendinosis of erector trunci muscle may cause severe pain after lumbar discectomy. In this paper we discuss pathophysiology, clinical appearance as well as specific diagnostic procedures and therapy. We want to point out that sacroiliac joint dysfunction must be taken into consideration if persistent pain occurs after discectomy.

[Diagnosis of recurrent intervertebral disk prolapse with nuclear magnetic resonance tomography]. / Diagnostik des Bandscheibenrezidivprolaps mittels Kernspintomographie.

Persisting low back pain after lumbar discectomy may have many reasons. Reoperation is likely to be successful if a recurrent disc prolapse is found. The sensitivity and validity of diagnostic tools used cannot as yet be considered to be optimal. For this reason in our study 130 patients who were supposed to have a recurrent disc herniation underwent MRI with and without application of Gadolinium DTPA. In all patients we saw enhancement in the spinal canal. Sensitivity of MRI as verified by reoperation was > 90%. Hence, we can recommend this diagnostic tool for the diagnosis of recurrent disc herniation.

The value of spinal magnetic resonance imaging (MRI) in locating prolapses of lumbar intervertebral discs.

Between 1986 and 1988 100 patients in whom MRI had been used to diagnose prolapses of lumbar intervertebral discs were admitted to the neurosurgical department of the Munich Technical University. MRI proved to be a valuable diagnostic technique, even if one has to concede certain limitations to the usefulness of the results when compared to conventional methods, particularly in such cases where clinical symptoms are not clear. Typical findings are illustrated and compared with those seen in MRI, whose relative importance is discussed.

[The use of propofol during diskectomy in neurosurgery]. / Zur Anwendung von Propofol bei Diskektomien in der Neurochirurgie.

The intravenous anaesthetic agent propofol has become more and more popular not only for induction but also for the maintenance of anaesthesia in all fields of surgery. For this purpose, different infusion rates and also combinations of propofol with opioids, nitrous oxide and volatile anaesthetic agents have been described. The present study was designed to find the best dosage regimen for short operations and rapid changes. The necessity for the frequently recommended standardized combination of propofol with opioids should be checked with respect to the cardiovascular effects. METHODS. A series of 60 patients (ASA I and II, age range 22-79 years) selected for discectomy were prospectively randomized to three groups. Half an hour before operation all patient received 0.5 mg atropine, 50 mg promethazine and 50 mg pethidine as i.m. premedication. In all groups anaesthesia was induced with propofol in a bolus dose of 2.5 mg/kg body weight over a period of approximately 45 s. After 5 mg atracurium the patients were intubated under 100 mg succinylcholine and normoventilated with 70% nitrous oxide and 30% oxygen. For relaxation 25 mg of atracurium were given. In group I propofol was administered in a dosage of 15 mg/kg body weight per hour for 10 min after induction. After this time the propofol infusion was reduced to 6 mg/kg body weight per hour. Group II received 0.1 mg fentanyl before induction. The dosage of propofol was similar to group I. In group III 0.1 mg of fentanyl was administered before induction and propofol was given with an infusion rate of 6 mg/kg body weight from the beginning. The following parameters were controlled and documented: systolic and diastolic blood pressure (SAP and DAP), heart rate (HF), end-expiratory carbon dioxide (eeCO2), inspiratory oxygen concentration (FiO2) and peripheral oxygen saturation (sO2). Recovery time was determined as the time from the end of the propofol infusion until eye-opening on command. RESULTS. In all groups anaesthesia could be induced and maintained without complications. There was a slight increase in SAP in group I after intubation, while in the groups with fentanyl a pronounced decrease of SAP was found simultaneously with induction of anaesthesia (Fig. 1). In group I HF showed significantly higher values after intubation and for the next 15 min than in group II and group III. A rapid and pronounced increase of end-tidal carbon dioxide occurred in the fentanyl groups with the beginning of spontaneous ventilation at the end of anaesthesia. There was a significantly longer recovery time in group II with fentanyl and initial higher propofol infusion rate. A correlation between dosage of propofol and recovery time could not be found. DISCUSSION. The results of this study demonstrate that a routine combination of propofol with opioids is not necessary even for painful surgical procedures if the propofol dosage is initially increased. There are differences in cardiovascular reactions between group I without and groups II and III with fentanyl, but in our patients these changes were of no clinical importance. An additional administration of fentanyl can prevent hypertensive reactions or tachycardia with intubation, but on the other hand fentanyl can also increase the cardial depression of propofol with a dangerous decrease in blood pressure and heart rate. Therefore in combination with opioids lower doses of propofol should be used for induction and maintenance of anaesthesia. If opioids are administered, signs of a residual postoperative respiratory depression have to be taken seriously.

[Recurrent sciatica caused by "conjoined nerve roots". Diagnosis, therapy, follow-up]. / Rezidivierende Ischialgien durch "conjoined nerve roots". Diagnostik, Therapie, Verlauf.

This study reports about 10 patients, with low back pain and sciatica caused by conjoined nerve roots. The described nerve root anomaly could produce sciatica even without the presence of a disc prolaps or another impingement. On computed tomography it is difficult to distinguish conjoined nerve roots from a disc prolaps. Two of these patients have been operated, eight of them have had conservative treatment. Our experiences show that the best results could be achieved with conservative treatment, especially with stabilising gymnastics and with transcutaneous nerve stimulation.

The role of magnetic resonance imaging (MRI) in the diagnosis of spondylodiscitis.

Spondylodiscitis is a well-known as well unavoidable complication of lumbar disc surgery. For diagnosis typical clinical symptoms and diagnostic procedures such as x-ray and scintigram are important but MRI proved to be the most sensitive and reliable. However, meaningful results can only be obtained with MRI if the measurement parameters are carefully considered, where by the field strength of the magnet plays a subordinate role. Therapy of spondylodiscitis using a light cast corset is described and it's advantages over other methods are shown.

[Non-surgical management of an infected ventriculo-atrial shunt]. / Nicht-operative Sanierung eines infizierten ventrikulo-atrialen Shunts.

We report on a 81-year old patient who showed clinical signs of a shunt infection eight months after implantation of a ventriculo-atrial shunt system Heyer-Schulte. The reason was identified to be a massive infection with staphylococcus albus. Elimination of the infection was achieved by intravenous administration of fosfomycine and local instillation of gentamycin into the valve. The follow-up was uneventful for more than two years until the death of the patient in January 1987.

Prophylaxis of postoperative lumbar spondylodiscitis.

Spondylodiscitis after lumbar disc surgery is a well-known complication with a frequency of 0.1 to 3%. According to the authors, the etiological factors are: combination of operated segment instability, damage to the lower and upper plates due to disc space curettage and transmission of germs. After treatment of 100 selected cases, all with increased risk of postoperative spondylodiscitis, distinct possibilities for prevention have been discovered. Basic treatment consisted of 3 x 80 mg perioperative doses of Gentamicin i.m. In addition a collagen sponge (Sulmycin Implant) containing 50 mg Gentamycin was inserted in the cleared disc spaces of 50 patients. Complications in this procedure were not observed. The following is recommended for prevention of postoperative spondylodiscitis: a careful operating technique, perioperative antibiotics, and in particularly endangered patients, insertion of Sulmycin Implant in the disc-spaces.

[Spondylodiscitis following lumbar intervertebral disk surgery. Clinical aspects--diagnosis--therapy]. / Die Spondylodiszitis nach lumbaler Bandscheibenoperation. Klinik--Diagnostik--Therapie.

From 1980 to 1986 6632 operations of the lumbar spine due to disc prolapse were carried out by the Department of Neurosurgery of the hospital of the Technical University of Munich. During this period we saw 14 cases of postoperative spondylodiscitis. Patients' main symptom was increasing low back pain. Physical examination showed difficulty in forward flexion of the body. The blood sedimentation rate was always examined: an average increase to 42/66 mm was recorded. X-ray examination of the lumbar spine and magnetic resonance imaging proved to be the most sensitive methods of investigation, better than scintigram and computed tomography. Our therapeutic management consists of fixation in normal position with a "Light Cast" corset and additional antibiotic therapy with cephadroxil. In comparison to other therapy methods, i.e. restcure, the advantage for our patients is that they can stay at home and move about. Therapy must be continued until the blood sedimentation rate is normal and radiological signs of consolidation can be seen for at least over 10 weeks. Good long-term results were seen in all patients.

[Perioperative cytostatic treatment of malignant supratentorial brain tumors with BCNU with special reference to tumor site]. / Perioperative cytostatische Behandlung supratentorieller maligner Hirntumoren mit BCNU unter spezieller Berücksichtigung der Tumorlage.

During the period from 1979 until 1986, sixty male and female patients were treated perioperatively in the Neurosurgical Department of the Surgical Clinic and OPD of the Munich Technical University with the alkylating agent BCNU. Up to five treatment cycles were employed, the first treatment cycle being initiated pre-operatively. In none of the cases were disorders of wound healing seen. Among these sixty patients there was one case of suspected BCNU lung and one case of massive leukopenia. Considering the rate of complications described in the international literature, this figure is extremely small. As to the study of the mean survival time, only 30 patients presenting supratentorial malignant tumours of comparable localisation were included. In light of these strict criteria the perioperative BCNU treatment at our clinic resulted in a mean survival time of 67.1 weeks which in comparison with the literature can be regarded as a good result. We would therefore only recommend cytostatic treatment with peroperative administration of BCNU.