Spinal epidural abscess: a meta-analysis of 915 patients.

Spinal epidural abscess (SEA) was first described in the medical literature in 1761 and represents a severe, generally pyogenic infection of the epidural space requiring emergent neurosurgical intervention to avoid permanent neurologic deficits. Spinal epidural abscess comprises 0.2 to 2 cases per 10,000 hospital admissions. This review intends to offer detailed evaluation and a comprehensive meta-analysis of the international literature on SEA between 1954 and 1997, especially of patients who developed it following anesthetic procedures in the spinal canal. In this period, 915 cases of SEA were published. This review is the most comprehensive literature analysis on SEA to date. Most cases of SEA occur in patients aged 30 to 60 years, but the youngest patient was only 10 days old and the oldest was 87. The ratio of men to women was 1:0.56. The most common risk factor was diabetes mellitus, followed by trauma, intravenous drug abuse, and alcoholism. Epidural anesthesia or analgesia had been performed in 5.5% of the patients with SEA. Skin abscesses and furuncles were the most common source of infection. Of the patients, 71% had back pain as the initial symptom and 66% had fever. The second stage of radicular irritation is followed by the third stage, with beginning neurological deficit including muscle weakness and sphincter incontinence as well as sensory deficits. Paralysis (the fourth stage) affected only 34% of the patients. The average leukocyte count was 15,700/microl (range 1,500-42,000/microl), and the average erythrocyte sedimentation rate was 77 mm in the first hour (range 2-50 mm). Spinal epidural abscess is primarily a bacterial infection, and the gram-positive Staphylococcus aureus is its most common causative agent. This is true also for patients who develop SEA following spinal anesthetics. Magnetic resonance imaging (MRI) displays the greatest diagnostic accuracy and is the method of first choice in the diagnostic process. Myelography, commonly used previously to diagnose SEA, is no longer recommended. Lumbar puncture to determine cerebrospinal fluid protein concentrations is not needed for diagnosis and entails the risk of spreading bacteria into the subarachnoid space with consequent meningitis; therefore, it should not be performed. The therapeutic method of choice is laminectomy combined with antibiotics. Conservative treatment alone is justifiable only for specific indications. Laminotomy is a therapeutic alternative for children. The mortality of SEA dropped from 34% in the period of 1954-1960 to 15% in 1991-1997. At the beginning of the twentieth century, almost all patients with SEA died. Parallel to improvements in the mortality rate, today more patients experience complete recovery from SEA. The prognosis of patients who develop SEA following epidural anesthesia or analgesia is not better than that of patients with noniatrogenic SEA, and the mortality rate is also comparable. The essential problem of SEA lies in the necessity of early diagnosis, because only timely treatment is able to avoid or reduce permanent neurologic deficits. The problem with spinal epidural abscesses is not treatment, but early diagnosis - before massive neurological symptoms occur" (Strohecker and Grobovschek 1986).

Lumbosacral extradural arachnoid cysts: diagnostic and indication for surgery.

No critical discussion of the indication for the surgical treatment of lumbosacral extradural arachnoid cysts is found in the literature. Therefore, we want to compare the results in patients with operative and conservative treatment to define standards for a good surgical result. Over a period of 9 years, we operated on eight patients with a lumbosacral extradural arachnoid cyst and treated eight others conservatively. Only three of the operated patients experienced a postoperative relief of pain, but none was symptom free. The only one with continuing success had a preoperative history of 1 year only. MRI scans without contrast agent were misinterpreted in one included and one excluded case. The results of conservative treatment were nearly the same as those of operative treatment. MRI is the best diagnostic tool, but a variety of sequences must be used. Patients with a short pain history and a clear neurological deficit profited most from surgery. Patients with slight and not clearly related uncharacteristic symptoms should be excluded from surgery.

[Primary unrecognized gunshot wound in the frontal skull base]. / Primär unerkannte Schussverletzung der Frontobasis.

BACKGROUND: Craniocerebral gunshot wounds demand a high degree of skill in clinical treatment. In addition to painstaking history, modern imaging techniques for preoperative diagnosis and interdisciplinary surgical treatment are important. CASE REPORT: Diagnosis and therapeutic principles are discussed on the basis of a case study of a 21-year-old soldier with an unusual craniocerebral gunshot wound.

[Midline and vertex epidural hematomas: clinical aspects, surgical indications and therapy]. / Epidurale Hämatome der Mittellinie und "Mantelkante": Klinik, Operationsindikation und Therapie.

Within a group of 315 epidural haematomas treated surgically 8 (2.5%) were located within the midline or at the vertex. The clinical symptoms may be small in frontally located haematomas. Paraparesis is caused by a haematoma localized at the vertex. The latter may be misinterpreted as a spinal trauma. The recognition of the hyperdense blood within the last slices of normal CT scans needs experience. It has been misinterpreted as hyperostosis of the skull. We present a group of eight personal cases. The sagittal skull suture was fractured in seven patients. One patient already had an 11-month history. Four cases were primary and had not been recognized. The prognosis depends on concomitant primary brain injuries. Early diagnosis with operative treatment given the best chance. Polytraumatized patients with concomitant injuries die. Slowly developing haematomas do not require acute surgery by in experienced surgeons. Sagittal sinus laceration must be treated by experienced neurosurgeons. It can be closed by suturing the dura to the bone with implanted collagen. In subacute cases the stiffness of the dura allows no normalization of the dura position. A dural graft is necessary for repositioning.

Endoscopic fenestration of the 3rd ventricular floor in aqueductal stenosis.

Six endoscopic fenestrations of the 3rd ventricular floor have been performed in patients with stenosis (SAS) of the aqueduct of Sylvius in our institute during the last two years. The endoscopic intraventricular landmarks were the Monro's foramen followed by the mamillary bodies. The fenestration instrument was a monopolar coagulation wire, the dilatation instrument was a balloon catheter. The patients included two newborns and four adults. The two newborns developed a recurrent hydrocephalus after 2 months. The four adults remained well after the operation. The only complication was edema (SIADH syndrome) in one case for 24 hours. Flow sensitised phase MRI showed a mirroring in the prestenotic CSF pulsation curve preoperatively. This, in combination with an increased intraventricular pulsation, is a sign of reduced capacity of the subarachnoid space at the cerebral surface. The postoperative patency of the fenestration with diminished intraventricular pulsation can be demonstrated with ECG retrogated phase MRI. There was a slow and incomplete decrease of the preoperative enlarged ventricular size. This operative method is a low-risk, minimal invasive alternative method to shunt implantation in adults with SAS.

[Six cases of petroclival meningiomas with main tumor site of the free tentorial rim--so-called tentorium notch meningiomas]. / Sechs Fälle von petroclivalen Meningeomen mit Haupttumorsitz am freien Tentoriumrand--sogennanten Tentoriumschlitzmeningeomen.

Petroclival meningiomas especially petroclival meningiomas with prevalent expansion to the tentorial notch are extreme rare. In the present paper we report about six patients with petroclival meningiomas of the tentorial notch who were operated in four years. The particular anatomical relations and the resulting symptoms and the neurosurgical procedures are discussed in detail. The postoperative state of the six patients is without exception satisfactory.

[Surgical indications in space-occupying contusion hemorrhage]. / Operationsindikation bei raumfordernden Kontusionsblutungen.

Traumatic intracerebral haematomas are a common neurosurgical emergency. The role of surgical removal is controversial. The diagnosis and treatment of life-threatening thoracic or abdominal haemorrhage is more urgent than are measures undertaken by the neurosurgeon. In the present paper we report on 318 patients with severe head injury. In 161 cases (38 female, 123 male) CT investigation showed a a resulting from contusion. About a third of each group of patients, both with and without contusion-induced haematomas, were 21-30 years old. The mortality rate was 18.6%. Multiple contusion haematomas occurred in 36%, and solitary ones in 64%. The diagnostic investigations showed contusion haematomas in isolation only in 10.6% of patients. All others had additional injuries: epidural haematomas in 24 cases, subdural haematomas in 29, depressed fractures of the skull in 6, and traumatic subarachnoid haemorrhage in 37. Only 10 patients underwent operative removal of their contusion haematomas by trepanation and 2 others by stereotactic puncture.

[Early and late complications of craniocerebral trauma. Chronic subdural hematoma/hygroma, carotid-cavernous sinus fistula, abscess formation, meningitis and hydrocephalus]. / Früh- und Spätkomplikationen nach Schädel-Hirn-Trauma. Chronisches Subduralhämatom/Hygrom, Karotis-Sinus-cavernosus-Fistel, Abszedierung, Meningitis und Hydrozephalus.

A group of 318 patients suffering from severe head injury, 51 of whom died of their (head) injury, is reviewed. A small contusional cerebral haemorrhage had occurred in 50.6%, and 30% had had basal skull fractures. In the entire group, 2.8% developed posttraumatic hydrocephalus. Shunt implantation was necessary between the 11th and 123rd posttraumatic days (mean 52nd). All patients with inflammatory problems, e.g. meningitis or intracranial abscess, developed posttraumatic hydrocephalus. In 10 of the 12 patients with hygromas, an operative procedure with bur hole trepanation was necessary. Half of the patients with hygromas were polytraumatized but only 25.85% of the entire group. Two patients in the group and a further 49 patients with chronic subdural haematomas were operated on by a bur hole trepanation and appropriate drainage for several days. In 2 cases the development of the chronic subdural haematoma had been documented by CAI. All patients with frontobasal skull fractures were operated on by a transethmoidal approach only the 1st day. Only 2 of the laterobasal skull fractures needed an operation. One of these caused was by a pneumocephalus. In 0.9% of the patients an intracranial abscess was present; these all had a basal skull fracture, 1 after gunshot injury. Among the patients with basal skull fractures 3.1% developed carotid artery-cavernous sinus fistula. One of these three fistulas has been documented as yielding to spontaneous closure. After reangiography for balloon occlusion an aneurysm was found. Following primary operation, 2.5% of patients required revision operation because of renewed bleeding. The posttraumatic treatment of the complications is discussed.

[Induction of brain tumors with methylnitrosourea. Comparative study of 2 strains of rats]. / Erzeugung von Hirntumoren mit Methylnitrosoharnstoff. Vergleichende Untersuchung an zwei rattenstämmen.

For clarifying the question with respect to the different incidence in various animal strains of the formation of cerebral tumours 10 BD II and Wistar rats were given methyl-nitrosourea (a weekly amount of 5 mg per kg of life-weight over a period of 35 weeks). After an average of 398 and 367 days half the number of animals in each group showed cerebral tumours. These primarily seem to be isomorphous gliomas which then show an increase in malignity.

[Intracranial late abscesses following injuries caused by grenade splinters]. / Intrakranielle Spätabszesse nach Granatsplitterverletzungen.

On the basis of 6 cases of late cerebral abscesses after lesions caused by shell-splinters treated by us, clinic, diagnostics and therapy of this complication are discussed in detail. In 3 patients there were no direct relations between the splinters and the abscesses so that further factors (age, vascular wall changes, and the like) must play a role in the formation of the abscesses; such vascular wall fibroses were found histologically in 3 of the examined abscess capsules. In 3 cases the bacteriological identification of the pathogens was possible. The treatment was carried out by employing puncture or extirpation or the combination of the two methods.

Experiments on the chemotheraphy of a transplantable glioblastoma in the rat, employing 1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea (CCNU).

A glioblastoma was induced in BD-II rats by weekly i.v. injections of methylnitrosourea and transplanted intracerebrally in numerous passages. The take rate was 100%. For the experiments with CCNU, solid pieces of tumour were implanted into the right parietal region. The cytostatically treated animals lived significantly longer. The untreated tumour rats had an average survival time of 18 days (counted from the time of transplantation), and the rats treated with CCNU had an average survival time of 28 days. The median values were 19 and 28 days.

[Medulloblastoma and pineoblastoma in monozygous twins (author's transl)]. / Medulloblastom des Kleinhirns und Pineoblastom bei eineiigen Zwillingen

Clinical and neuropathological findings in monozygous twin sisters are reported. Twin I died at age 5 months from a cerebellar medulloblastoma, whereas her sister died at age 16 months from a pineoblastoma. The tumors are considered similar referring to histogenesis, structural peculiarities and growth. Therefore, the twins are seen as concordant for the tumor type.

[Fluid carbenicillin levels after intravenous administration]. / Liquorspiegelbestimmungen nach intravenöser Gabe von Carbenicillin

Intravenous infusion of carbenicillin was followed by a determination of the concentration of this antibiotic in both the liquor and serum. The examinations, of which the results are reported in this paper, were made on six patients who had undergone surgical operations to the posterior cranial fossa and on whom lumbar punctures were postoperatively performed every day, as well as on seven hydrocephalic patients where a temporary relief of pressure was obtained by draining excess liquor. The level of carbenicillin in the liquor were found to enable even gram-negative problem germs (e.g., Proteus germs) to be controlled.

[Combined appearance of an intracranial and spinal meningioma in a case of Recklinghausen's disease]. / Kombiniertes Auftreten eines intrakraniellen und spinalen Meningioms bei einem Fall von Morbus Recklinghausen

In a young man with Recklinghausen's disease a large dextral wing-of-sphenoid meningioma and a spinal meningioma were extirpated at an interval of one month. A couple of months later further interventions were necessary because of a bilateral acoustic neurinoma. The patient's mother had multiple intracranial meningiomas and also a bilateral acoustic neurinoma. The medical history of the patient is reported. Also discussed are problems associated with the diagnosis of the spinal meningioma.