Evaluation of sterile glove usage on digital tactile sensitivity using the Grating Orientation Task.

Introduction: Surgical glove use may be associated with a decrease in tactile sensitivity, with thicker gloves or double-gloving techniques further altering sensation. This study evaluates digital tactile sensitivity by use of a Grating Orientation Task (GOT) with multiple sterile gloving techniques (no gloves, single standard gloving, double standard gloving, orthopedic gloves, and micro-thickness gloves). Methods: Each participant performed the GOT at increasing grating widths until correctly noting orientation in ≥8 of 10 trials with multiple glove types or double-gloving technique. Glove order was randomly assigned and participants were blinded to the orientation and dome size. Results: All gloves except micro-thickness gloves showed increased threshold sensitivity values (i.e. worse fingertip sensitivity) when compared to control (micro:control, p = 0.105, others:control, p < 0.05). Single-layer gloves showed no significant difference in sensitivity when compared to orthopedic (p = 0.06) or double-layer latex gloves (p = 0.26). Discussion: Standard latex gloves decreased fingertip sensitivity when evaluated with the GOT. Double-layer and orthopedic latex gloves do not decrease sensitivity when compared with single-layer gloving. Micro-thickness gloves may provide similar tactile sensitivity to no surgical glove.

Radiation exposure associated with percutaneous fluoroscopically guided lag screw fixation for sacroiliac luxation in dogs.

OBJECTIVE: To determine radiation exposure to surgical personnel and to evaluate the accuracy of a modified percutaneous lag screw fixation technique for sacroiliac luxation (SIL) under fluoroscopic guidance in dogs. STUDY DESIGN: Cadaveric experimental study. SAMPLE POPULATION: Seventeen beagle cadavers with iatrogenic SIL. METHODS: Seventeen beagles with iatrogenic SIL underwent reduction and stabilization with 3.5-mm screws. Hypodermic needles (14 gauge) and fluoroscopy were used to orient two Kirschner wires for temporary stabilization and to guide drilling of glide and pilot holes using cannulated drill bits. Duration of surgery and radiation exposure were recorded. Postoperative computed tomographic evaluation of screw position and angulation was performed. RESULTS: Average time for fixation was 15.85 minutes (range, 6.37-33.5). Cumulative radiation doses of 0.4 mrem for the dominant arm of the assistant and 0 mrem for the primary surgeon were recorded. The mean dorsoventral and craniocaudal screw angles were 0.68° ± 3.4° (range - 5.4° to 9.5°) and 1.9° ± 3.2° (range - 4.3° to 9.1°), respectively. Sixteen of the 17 dogs had 100% sacral screw purchase, with the remaining case achieving 93.4% purchase. CONCLUSION: Fluoroscopy-assisted percutaneous placement of 3.5-mm cortical screws in lag fashion performed with 14-gauge needles in conjunction with Kirschner wires and cannulated drill bits yielded repeatable accurate screw placement with low levels of ionizing radiation exposure to the surgical team. CLINICAL SIGNIFICANCE: The described technique may be a viable method for minimally invasive osteosynthesis fixation of SIL with low levels of radiation exposure to the surgical team. These results provide evidence to support further evaluation of radiation exposure in clinical cases and can aid in study design and sample size determination.

Cefazolin concentration in surgically created wounds treated with negative pressure wound therapy compared to surgically created wounds treated with nonadherent wound dressings.

OBJECTIVE: To compare cefazolin concentrations in biopsied tissue samples collected from surgically created wounds treated with negative pressure wound therapy to those collected from surgically created wounds treated with nonadherent dressings. STUDY DESIGN: Prospective, controlled, experimental study. ANIMALS: Adult female spayed Beagles (n = 12). METHODS: Full thickness cutaneous wounds were created on each antebrachium (n = 24). Immediately after surgery, cefazolin (22 mg/kg intravenously [IV]) was administered to each dog and continued every 8 hours during the study. The right wound was randomly assigned to group I or group II whereas the wound on the contralateral antebrachium was assigned to the other group. Group I wounds were treated with negative pressure wound therapy (NPWT) and group II wounds were treated with nonadherent dressings for 3 days. Dressings were changed and tissue biopsies obtained from wound beds at 24 hours intervals for both groups. Cefazolin wound tissue and plasma concentrations were measured by liquid chromatography mass spectrometry (LC-MS/MS). Blood samples for measuring plasma cefazolin concentrations were collected before biopsy sampling. At the time of surgery and at each subsequent bandage change, wound beds were swabbed and submitted for aerobic and anaerobic culture. RESULTS: After initiating cefazolin treatment, wound tissue antibiotic concentrations between treatment groups were not significantly different at any sampling time. Similarly, after initiating cefazolin treatment, plasma cefazolin concentrations were not significantly different at any sampling time for individual dogs. CONCLUSIONS: Using a canine experimental model, NPWT treatment of surgically created wounds does not statistically impact cefazolin tissue concentrations when compared with conventional nonadherent bandage therapy.

Lack of cardiac fibrosis in a new model of high prorenin hyperaldosteronism.

The aim of the present study was to test the hypothesis that elevation of prorenin in plasma is sufficient to induce cardiac fibrosis. Normotensive cyp1a1ren-2 transgenic rats with normal plasma prorenin and aldosterone levels were given 0.125% indole-3-carbinol (I3C) orally for a period of 12 wk. Plasma prorenin and aldosterone levels were determined in 4-wk intervals, and cardiac marker enzymes for hypertrophy, fibrosis, and oxidative stress as well as cardiac pathology were investigated. In I3C-treated cyp1a1 ren-2 transgenic rats, plasma prorenin concentrations were >100-fold elevated (> or = 7.1 + or - 2.6 microg ANG I.ml(-1).h(-1) vs. < or = 0.07 + or - 0.1; P < 0.001), whereas active renin levels were suppressed (0.09 + or - 0.02 vs. 0.2 + or - 0.1; P < 0.05). Aldosterone concentrations were elevated three- to fourfold for a period of >4 wk (574 + or - 51 vs. 160 + or - 68 pg/ml; P < 0.01). After 12 wk of I3C, rats exhibited moderate cardiac hypertrophy (heart weight/body weight 2.5 + or - 0.04 vs. 3.1 + or - 0.1 mg/g; P < 0.01). There was a slight increase in mRNA contents of endothelin 1 (1.21 + or - 0.08 vs. 0.75 + or - 0.007; P < 0.001), NADP oxidase-2 (1.03 + or - 0.006 vs. 0.76 + or - 0.04; P < 0.001), transforming growth factor-beta (0.99 + or - 0.06 vs. 0.84 + or - 0.04; P < 0.05), collagen type I (1.32 + or - 0.32 vs. 0.94 + or - 0.18; P < 0.05), and intercellular adhesion molecule-1 (1.12 + or - 0.12 vs. 0.84 + or - 0.08; P < 0.05). These genes are known to be stimulated by the renin-angiotensin system. There were no histological signs of fibrosis in the heart. We found that prorenin and aldosterone alone are not sufficient to induce considerable cardiac fibrosis in the absence of sodium load.

Neuroendoscopic treatment for colloid cysts of the third ventricle: the experience of a decade.

OBJECTIVE: Microsurgical resection or ventriculoperitoneal shunt placement was for a long time the only means of treatment for patients with colloid cysts. In the past few years, however, endoscopic procedures have gained increasing significance and have been used more widely. Long-term results are now available for the first time, which enabled us to evaluate this method and assess its future relevance. METHODS: Twenty patients with symptomatic colloid cysts of the third ventricle have been treated endoscopically in our department during the past 10 years. Retrospective analysis and follow-up of the patients' clinical and radiological outcomes were performed. RESULTS: In the early postoperative period, 18 patients had excellent outcomes, with clinical signs improving immediately. One patient experienced intraoperative hemorrhage followed by temporary postoperative psychosis and IIIrd cranial nerve palsy. Another patient remained shunt-dependent because of aseptic meningitis after the endoscopic procedure. In the long-term follow-up, one patient had to be reoperated to treat cyst recurrence. The operative time was strongly dependent on the cyst material as well as on the surgeon's experience with endoscopic techniques; it varied between 60 and 300 minutes (mean operative time, 200 min). The average hospitalization time was 9 days. Long-term follow-up ranging from 1 to 10 years showed a clear benefit in each patient. In three individuals with pre- and postoperative short-term memory deficits and in one patient who complained of headaches, symptoms resolved gradually during the first few months after surgery. The patient with intraoperative hemorrhage complained of slight permanent short-time memory deficit. The analysis of postoperative computed tomographic and magnetic resonance imaging scans revealed a remaining cyst wall in the majority of patients and an inconsistent decrease in ventricular size. Postoperative cine magnetic resonance imaging studies showed normalization of cerebrospinal fluid flow in 17 patients. CONCLUSION: Continued improvement of endoscopic techniques and instruments, together with good long-term results in endoscopically treated patients, have established this method as an alternative to microsurgical techniques and might even set a new standard for treatment.

The role of neuroendoscopy in the management of solid or solid-cystic intra- and periventricular tumours.

OBJECTS: The purpose of this study was to describe the surgical strategies of neuroendoscopic treatment in patients with solid or solid-cystic peri- and intraventricular tumours. Analysis of the postoperative histopathology and complication of neuroendoscopic interventions was also performed. BACKGROUND: A number of intracranial tumours do not ultimately require aggressive surgical intervention. Either definite or palliative treatment for the intra- and periventricular lesions could be accomplished using various neuroendoscopic techniques, depending on the histopathological diagnosis and aim of therapeutic intervention. MATERIALS AND METHODS: Between 1994 and 2004, 46 patients with newly diagnosed solid or solid-cystic peri- and intraventricular tumours underwent neuroendoscopic procedures Twenty patients had associated hydrocephalus requiring the cerebrospinal fluid diversion procedures. Since 1997, neuronavigation has been applied to selected cases. RESULTS: Obstructive hydrocephalus was treated sufficiently by endoscopic third ventriculostomy or endoscopic stent placement. Partial or total extirpation of solid tumour was achieved in four cases. The majority of pathological examinations revealed astrocytoma (23), craniopharygioma (7) and metastasis (2). Subsequent mode of treatment such as chemotherapy, radiation therapy or microscopic surgery was determined according to the pathological findings. There were three transient morbidities and one permanent deficit, but no operative mortality. CONCLUSION: Transventricular endoscopic approach is an effective and reliable alternative treatment of newly diagnosed peri- and intraventricular lesions. Neuroendocopic procedures offer the opportunity to combine tumour biopsy and treatment of hydrocephalus. In selected patients, partial or total tumour removal could be performed.

Peri-operative quality of life assessment in endoscopically treated patients with pineal region tumours.

BACKGROUND: Therapeutic modalities for pineal region tumours are still matter of debate. Endoscopic treatment is a minimally invasive approach. The aim of this study was to assess the quality of life of patients with pineal region tumours who underwent endoscopic procedures. MATERIALS AND METHODS: Eight patients (male:3, female 5) were included in this study. Post-operative evaluation of surgical outcome in terms of quality of life (QoL) was performed using the Quality of Life Questionnaire (QLQ-C30). The patient's outcome scores were compared with normative outcome values of the German population. Pre-operative and post-operative global QoL and symptoms such as headache, visual disturbance, gait disturbance, cognitive function and unconsciousness were documented. Descriptive and explorative statistics were performed. RESULTS: There were no significant differences between the normal German population and the endoscopically treated patients in different health domains and measures of QLQ-C30 (physical functioning 87.5%, emotional functioning 50%, cognitive functioning 50%, social functioning 62.5%; percentage represents regular functioning). Improved quality of life could be demonstrated in short-term (3-12 months, n = 3) and long-term (21-29 months, n = 5) follow-up. Global QoL improved significantly (p < 0.001; t-test) post-operatively. The following changes between pre-operative and post-operative clinical symptoms were found (headache 87.5%/62.5%, visual disturbance 50%/25%, gait disturbance 87.5%/25%, cognitive functioning 75%/37.5%, unconsciousness 25%/-). CONCLUSION: Endoscopic treatment of patients with pineal region tumours produces improved post-operative quality of life in all health domains. Therefore, the endoscopic approach should be considered as an alternative treatment in patients with newly diagnosed pineal tumours and/or related hydrocephalus.

Present status of known and possible outcomes in neurosurgery: a survey of outcome assessment.

OBJECTIVES: In the area of health care research, quality of life (QoL) is considered as a diagnostic tool for problem-oriented care of postoperative cancer patients. The aim of this study was to assess the attitude of neurosurgeons towards the different outcome measurements. MATERIALS AND METHODS: This prospective study was conducted between the 15(th) and 18th of June 2005 during the third world conference of the International Study Group on Neuroendoscopy (ISGNE) in Marburg, Germany. Copies of the questionnaire that was generated for this purpose were distributed to the participants from all over the world. Respondents were asked to return the completed questionnaire to the registration/information desk. The acquired data from the questionnaires were transferred to Excel spreadsheet. Only data from completely filled out questionnaires were included in the descriptive and explorative analysis. RESULTS: Forty of the 150 questionnaires that were distributed were complete without missing values and mistakes. Data from these 40 questionnaires were used for analysis. Sixty eight percent (27:40) of the neurosurgeons considered mortality as the first or the second rank of outcome measurement, whereas morbidity was also found to be the other important outcome measurement (the first or the second rank of outcome measurement) in 45% (18:40) of the neurosurgeons. Improved QoL was considered as the third or the fourth priority of outcome measurement in 53% (22:40) of the respondents. Although from these data, it may be difficult to infer that there is a real transfer of QoL concept from the scientific theory and the measurement level into clinical application. However, this may reflect a change in attitude of the surgeon. CONCLUSION: Besides disseminating new QoL concepts through publication and information technology, an implementation of this contemporary concept would provide a postoperative neurosurgical patient an optimal and rapid therapy according to the disclosed problems in the somatic, psychological, and social domains. Therefore, a QoL profile that can be used in each group of neurosurgical patient should be created.

Secretory meningioma: immunohistochemical findings and evaluation of mast cell infiltration.

Secretory meningiomas constitute a relatively rare subtype of meningiomas, accounting for only 1.1% at our institution, with a 6:1 predominance of female patients. This study aimed to obtain more information about the immunohistochemical characteristics of this histological entity, and to analyse the effects of histological factors such as the presence of mast cells on the radiological evidence of surrounding tumour oedema that frequently occurred in this subtype of meningioma. Fourteen cases of secretory meningioma were examined. Relevant clinical information was obtained from the patient files. Peritumoural oedema was determined either by CT or MRI scans and graded as small, moderate and severe. In order to perform the quantitative evaluation of mast cells in secretory meningiomas in a comparison with other meningiomas, 14 non-secretory meningiomas were randomly selected and used as a control group. The immunohistochemical staining of carcinoembryonic antigen was positive within the secretory droplets and the cells surrounding them in all cases. Ki 67 (MIB 1) proliferative index mean values were 2.4%, indicating low expression in all secretory meningiomas. Moreover, from our statistical analysis, there is no clear-cut pattern of various types of cytokeratins emerging in secretory meningiomas. The secretory meningiomas were characterized by a significantly increased number of mast cells as compared with non-secretory meningiomas of different grades. As the present clinical findings and laboratory results could not confirm a correlation between mast cell density and radiological evidence of oedema, further studies of mediators are warranted.

Enlarged perivascular spaces mimicking multicystic brain tumors. Report of two cases and review of the literature.

The authors present two cases in which enlarged Virchow-Robin spaces were located in the basal ganglia and the thalamomesencephalic region. The incidence of such huge cystic lesions is extremely rare. The expanding nature of these lesions, demonstrated by the patients' progressive symptoms due to compression of the adjacent brain parenchyma and obstructive hydrocephalus, mimicked that of brain tumors. The two patients were successfully treated by neuroendoscopic cystocisternostomy or ventriculocystostomy. To the authors' knowledge there have been only two published reports on expanding Virchow-Robin spaces that produced a compressive effect or consequent hydrocephalus and were directly fenestrated using neuroendoscopic techniques. Neuroendoscopy appears to offer an effective surgical option in the treatment of symptomatic Virchow-Robin spaces.

Endoscopic third ventriculostomy for obstructive hydrocephalus.

The indications for neuroendoscopy are not only constantly increasing, but even the currently accepted indications are constantly being adjusted and tailored. This is also true for one of the most frequently used neuroendoscopic procedures, the endoscopic 3rd ventriculostomy (ETV) for obstructive hydrocephalus. ETV has gained popularity and widespread acceptance during the past few years, but little attention has been paid to the techniques of the procedure. After a short introduction describing the history of ETV, an overview is given of all the different techniques that have been and still are employed to open the floor of the 3rd ventricle. The spectrum of indications for ETV has been widely enlarged over the last years. Initially, the use of this procedure was restricted to patients older than 2 years, to patients with an obvious triventricular hydrocephalus, and to those with a bulging, translucent floor of the 3rd ventricle. Nowadays, indications include all kinds of obstructive hydrocephalus but also communicating forms of hydrocephalus. The results of endoscopic procedures in treating these pathologies are given under special consideration of shunt technologies. In summary, from the review of the publications since the first ETV performed by Mixter in 1923, this technique is the treatment of choice for obstructive hydrocephalus caused by different etiologies and is an alternative to cerebrospinal fluid shunt application.

The evolution of stereotactic guidance in neuroendoscopy.

OBJECTIVES: To evaluate the advantages and limitations of the utilized system in accordance with the operative indications of stereotactic neuroendoscopy. PATIENTS AND METHODS: We reviewed our collective experience of computer-assisted stereotaxy (frame-based and frameless) and virtual endoscopy in neuroendoscopic surgery from 1982 to 2003. Sterotactic guiding systems (frame-based and frameless) have been used to perform more than 450 neuroendoscopic operations at our institute. RESULTS: Even though image guidance is not essential in all cases, technological developments have definitely been one of the major factors in improving outcomes. Planning endoscopic trajectory and intraoperative orientation within the ventricular system or other cavities are the main indications for its application. CONCLUSIONS: No surgical tool, no matter how accurate, can be a substitute for thoughtful and methodical pre-operative planning. Image-guided technologies are applied in order to make endoscopic surgery safer, faster and more easily reproducible. Despite the high initial cost of the equipment, overall expenses are expected to be reduced because of greater operative efficiency and shorter hospital stay.

Neuroendoscopic stent procedure in obstructive hydrocephalus due to both foramina of monro occluding craniopharyngioma: technical note.

BACKGROUND: The development of various neuroendoscopic surgical instruments has offered more options for endoscopic procedures in the treatment of intraventricular tumors. Not only tumor biopsy or tumor resection but also restoration of an obstructed cerebral spinal fluid (CSF) pathway can be performed using the same approach. METHOD: A 76-year-old woman with a cardiac pacemaker for an underlying heart disease was diagnosed with obstructive hydrocephalus because of a third ventricular tumor 8 years ago. The patient had been treated with ventriculo-peritoneal shunt placement. At admission she presented with a subcutaneous infection of the shunt catheter and an abdominal mass of unknown etiology. Neuroendoscopic stenting between lateral and third ventricle was performed to restore the obstructed CSF pathway, and the infected shunt system was removed in the same setting. RESULT: The postoperative course was uneventful. Contrast ventriculography demonstrated a restored CSF pathway between the lateral and third ventricle. Histologic examination of the intraventricular tumor revealed a craniopharyngioma, and the abdominal mass was diagnosed as a gastrointestinal adenocarcinoma. CONCLUSION: The neuroendoscopic foraminoplasty technique should be considered as an alternative treatment for patients who present with an obstructive hydrocephalus caused by a tumor that occludes both foramina of Monro when shunt placement or endoscopic third ventriculostomy is not feasible.

Isolated paramedullary hemangioblastoma originating from the first cervical nerve root: case report.

STUDY DESIGN: A retrospective case of an isolated paramedullary hemangioblastoma originating from the first cervical root is reported. OBJECTIVE: To describe an uncommon type of spinal hemangioblastoma and its operative treatment. SUMMARY OF BACKGROUND DATA: Spinal hemangioblastoma, rare finding accounting for approximately 1.5% to 2.5% of all spinal cord tumors, may have an intramedullary, extramedullary, or extradural location. Cervical hemangioblastomas occur in approximately 45% of the cases and are intramedullary in about 83% of the cases. METHODS: A 59-year-old man presented with acute subarachnoid hemorrhage in the basal cisterns. Four-vessel angiography showed a highly vascular small tumor at the dorsolateral side of the cervicomedullary junction fed by a branch of the vertebral artery. The lesion was surgically removed. RESULTS: Total removal of the lesion was achieved after identification of both the arterial feeder and the draining vein with the aid of microvascular Doppler sonography. There were no complications, and the patient did well after surgery. CONCLUSIONS: Although hemangioblastomas occurring in the cervicomedullary area usually may cause progressive neural compression, occasionally they also can present clinically as acute subarachnoid hemorrhage. This situation requires urgent and adequate treatment as in the reported case.

Neuroendoscopic treatment for colloid cysts of the third ventricle: the experience of a decade.

OBJECTIVE: Microsurgical resection or ventriculoperitoneal shunt placement was for a long time the only means of treatment for patients with colloid cysts. In the past few years, however, endoscopic procedures have gained increasing significance and have been used more widely. Long-term results are now available for the first time, which enabled us to evaluate this method and assess its future relevance. METHODS: Twenty patients with symptomatic colloid cysts of the third ventricle have been treated endoscopically in our department during the past 10 years. Retrospective analysis and follow-up of the patients' clinical and radiological outcomes were performed. RESULTS: In the early postoperative period, 18 patients had excellent outcomes, with clinical signs improving immediately. One patient experienced intraoperative hemorrhage followed by temporary postoperative psychosis and IIIrd cranial nerve palsy. Another patient remained shunt-dependent because of aseptic meningitis after the endoscopic procedure. In the long-term follow-up, one patient had to be reoperated to treat cyst recurrence. The operative time was strongly dependent on the cyst material as well as on the surgeon's experience with endoscopic techniques; it varied between 60 and 300 minutes (mean operative time, 200 min). The average hospitalization time was 9 days. Long-term follow-up ranging from 1 to 10 years showed a clear benefit in each patient. In three individuals with pre- and postoperative short-term memory deficits and in one patient who complained of headaches, symptoms resolved gradually during the first few months after surgery. The patient with intraoperative hemorrhage complained of slight permanent short-time memory deficit. The analysis of postoperative computed tomographic and magnetic resonance imaging scans revealed a remaining cyst wall in the majority of patients and an inconsistent decrease in ventricular size. Postoperative cine magnetic resonance imaging studies showed normalization of cerebrospinal fluid flow in 17 patients. CONCLUSION: Continued improvement of endoscopic techniques and instruments, together with good long-term results in endoscopically treated patients, have established this method as an alternative to microsurgical techniques and might even set a new standard for treatment.

Successful management of a symptomatic fusiform dilatation of the internal carotid artery following surgery of childhood craniopharyngioma.

INTRODUCTION: The development of fusiform dilatation of internal carotid artery is one of the vascular complications that can follow surgery for craniopharyngioma and other suprasellar tumours in children, but its pathogenesis and the line of management are still controversial. CASE REPORT AND DISCUSSION: We report a child who presented with a giant fusiform aneurysm involving the supraclinoid portion of the internal carotid artery after total removal of a craniopharyngioma and review the literature on related cases. The treatment of this phenomenon and its possible pathogenesis are discussed.

Image fusion for skull base neuronavigation. Technical note.

An automatic image fusion module (BrainLab, Munich, Germany) is used for the fusion of the magnetic resonance (MR) imaging and computed tomography (CT) data sets. The procedure of image fusion takes 5 minutes prior to surgery. The image fusion of CT and MR imaging data visualizes the skull base and tumor margins clearly. Color display of the different data sets allows the tumor and the skull base to be distinguished easily. The fused CT data in bone window mode provides useful additional information on the osseous skull base.

Novel multipurpose bipolar instrument for endoscopic neurosurgery.

OBJECTIVE: Hemorrhage control in endoscopic neurosurgery is critical because of the lack of suitable instruments for coagulation. One reason for this problem is that miniaturization of the instruments is still a technical problem. In this article, we present a solution: the use of bipolar microforceps with a small diameter of 1.5 mm. METHODS: With the use of modern synthetic and metallic materials, the construction of the bipolar microforceps was designed without the use of mechanical joints. All movable elements are integrated within the instrument shaft. This design provides optimal visibility of the operating field because the sheath has a diameter of only 1.5 mm along its entire length. Therefore, this instrument is compatible with most working channels of neuroendoscopes. RESULTS: The new, joint-free design of the forceps and the electric insulation of the branches were the technical innovations that led to the development of this novel, multipurpose instrument. CONCLUSION: This new instrument may enhance endoscopic resection and shrinkage of cystic lesions and may offer new possibilities in endoscopic tumor resection and the treatment of hemorrhage.