Pallidal deep brain stimulation in patients with cervical dystonia and severe cervical dyskinesias with cervical myelopathy.

OBJECTIVES: Surgical treatment of complex cervical dystonia and of cervical dyskinesias associated with cervical myelopathy is challenging. In this prospective study, the long term effect of chronic pallidal stimulation in cervical dystonia and on combining the technique with spinal surgery in patients with severe cervical dyskinesias and secondary cervical myelopathy is described. METHODS: Eight patients with a history of chronic dystonia who did not achieve adequate benefit from medical treatment or botulinum toxin injection participated in the study. Five patients had complex cervical dystonia with tonic postures and phasic movements. Three patients had rapidly progressive cervical myelopathy secondary to severe cervical dyskinesias and dystonia in the context of a generalised movement disorder. Quadripolar electrodes were implanted in the posteroventral lateral globus pallidus internus with stereotactic CT and microelectrode guidance. In the three patients with secondary cervical myelopathy, spinal surgery was performed within a few weeks and included multilevel laminectomies and a four level cervical corporectomy with spinal stabilisation. RESULTS: Improvement of the movement disorder was noted early after pallidal surgery, but the full benefit could be appreciated only with a delay of several months during chronic stimulation. Three months after surgery, patients with cervical dystonia had improved by 38% in the severity score, by 54% in the disability score, and by 38% in the pain score of a modified version of the Toronto western spasmodic torticollis rating scale. At a mean follow up of 20 months, the severity score had improved by 63%, the disability score by 69%, and the pain score by 50% compared with preoperatively. There was also sustained amelioration of cervical dyskinesias in the three patients who underwent spinal surgery. Lead fractures occurred in two patients. The mean amplitude needed for chronic deep brain stimulation was 3.8 V at a mean pulse width of 210 micros, which is higher than that used for pallidal stimulation in Parkinson's disease. CONCLUSIONS: Chronic pallidal stimulation is effective for complex cervical dystonia and it is a useful adjunct in patients with cervical dyskinesias and secondary cervical myelopathy who undergo spinal surgery.

Central lumbar disc herniation.

UNLABELLED: A follow-up study which describes the experience of the Department of Neurosurgery in Berne in the treatment of patients with central lumbar disc herniation (CLDH). BACKGROUND DATA: The anatomical position of lumbar disc herniation, in general, does not seem to affect postoperative outcome. However, according to other studies a subgroup of patients with central lumbar disc herniations appears to have poorer results. OBJECTIVES: The aim of the present study was to assess clinical outcome in a recent cohort of patients, to investigate whether there is a difference in outcome with regard to the surgical approach (unilateral vs bilateral) and to compare the postoperative results between the subcategories of CLDH: central massprolaps (CMP) and central contained disc herniation (CCDH). METHODS: Between 1990 and 1997, 40 out of 3150 patients operated on for lumbar disc herniation were diagnosed with CLDH (1.2%). The patients were operated on through unilateral or bilateral fenestrations with microdiscectomy. Recent follow-up studies were obtained by standardized questionnaires. The retrospective investigation was performed by an unbiased observer. RESULTS: Long-term follow-up was available for 34 of the 40 patients (85%) at a mean of 3.3 years. Eight patients had an excellent result (24%), 15 patients a good result (44%), 8 patients a fair (24%) and 3 patients had a poor result (9%). Overall, the operation was considered successful in 68% of patients. There was no statistically significant difference in outcome in patients with CMP as compared with those with CCDH (75% versus 64%). There was also no significant difference for better outcome between bilateral as compared with unilateral approaches. CONCLUSIONS: Postoperative outcome of central lumbar disc herniation (CLDH) is poorer as compared with other types of lumbar disc herniation. The reason seems to be the anatomical position of the disc herniation with a peculiar derangement of the disc architecture. The surgical approach itself or the subcategories of CLDH appear to have only minor impact on postoperative outcome. Interlaminar fenestrations, in general, are appropriate for removal of the disc fragments.

[Long-term results of diskectomy and primary spondylodesis in treatment of lumbar disk hernia]. / Langzeitergebnisse der Diskektomie und der primären Spondylodese in der Behandlung der lumbalen Diskushernie.

The indication for spine fusion in combination with diskectomy it neither clearly defined nor widely accepted. It largely depends on the specialist to whom the patient is referred. While orthopedists often perform primary fusions, neurosurgeons hardly ever do so, no matter what the nature of the complaint is. Therefore, the selection of the procedure seems to be a rather random choice. The question is not whether the combined operation or the simple disc excision is superior in itself, but which of the two should be chosen in a given case. For patients with disc displacement and radicular pain as the predominant symptom, undercutting hemilaminectomy and disc excision will generally yield satisfying results. The main indication for a combined operation is a history of instability complaints long before radicular pain caused by the disc displacement appears. Since the number of patients (of all age groups) that require a disc operation is ever increasing, the selection of patients suited for a combined operation is becoming more and more important, so as to bring down the number of secondary fusions for the treatment of invalidating low back pain after disc excision. The aim of our clinical research is to test the criteria for the selection of patients for the combined operation by taking into account both patients who underwent a combined operation and others whose postoperative condition was such as to require a secondary fusion within one year after diskectomy. In the majority of these cases, one can presume that the fusion should have been carried out on the occasion of the first operation. 26 (90%) out of 29 patients showed a good result three months after the combined operation; 25 (86%) were still satisfied four years later. This confirms that patients with a long history of low back pain as a symptom of instability--in addition to the recent symptoms of the herniation--and those with a significant dislocation of one vertebral body (retrolisthesis, spondylolisthesis and pseudospondylolisthesis), too, should be examined in view of a possible combined operation. However, the combined operation is needed in no more than about three to four per cent of all diskectomies.

[Misoprostol and cimetidine in the treatment of duodenal ulcer. A multicenter Swiss double-blind study]. / Misoprostol und Cimetidin bei der Behandlung des Ulcus duodeni. Eine multizentrische Schweizer Doppeltblindstudie.

The efficacy and tolerance of misoprostol a synthetic prostaglandin E1 analogue-and of cimetidine were evaluated in the treatment of duodenal ulcer following a double blind multicenter design. A group of Swiss gastroenterologists recruited 119 patients with endoscopically proven acute duodenal ulcer. They were enrolled and treated according to a uniform protocol either with misoprostol 4 X 50 micrograms daily, with misoprostol 4 X 200 micrograms daily or with cimetidine 4 X 300 mg daily. Patients who were healed after 4 or 8 weeks were followed during 6 months. Cumulative healing rates at 4 weeks in groups receiving misoprostol 200 micrograms, misoprostol 800 micrograms or cimetidine 1200 mg daily were 42%, 58% and 71% respectively. Patients treated with cimetidine showed a more rapid improvement of symptoms than patients treated with misoprostol. Symptomatic recurrences after ulcer healing occurred in almost 40% of the patients within 6 months, irrespective of the type of acute ulcer treatment. Risk factors for slowed healing and increased rate of recurrence were evaluated in the present study, and the results were compared with the results of two previous trials performed according to a similar protocol. Smoking appeared to slow healing and to favor relapses. Moderate consumption of alcohol appeared to decrease the relapse rate. In the present trial, ulcer size was associated with ulcer pain but not with ulcer healing.