Stereotactic radiosurgery of a papillary tumor of the pineal region: case report and review of the literature.

BACKGROUND/AIMS: Papillary tumors of the pineal region are a recently described very rare group of primary CNS neoplasms. Because of their rarity, it has proven to be difficult to establish the optimal therapy. Furthermore, microsurgical resection of pineal region neoplasms is associated with quite a high morbidity. We report the first case of stereotactic radiosurgery of a histologically confirmed papillary tumor of the pineal region. METHODS: After establishing the diagnosis by stereotactic biopsy, the patient was treated with stereotactic radiosurgery in a Gamma Knife unit. RESULTS: Five years after treatment, the tumor size is still decreasing, showing a good response to the treatment. CONCLUSIONS: Stereotactic radiosurgery should be considered a treatment option in these surgically challenging tumors.

Frameless navigated biopsy with the BrainLAB® VarioGuide system: a technical note.

OBJECTIVE: Implementation of a new neuronavigation system in the department included the opportunity to change the brain biopsy procedures from a frame-based system to a frameless system--the BrainLAB® VarioGuide. We report our first 20 consecutive procedures within 2 years, analyzing the effectiveness of this new tool. PATIENTS, MATERIALS, AND METHODS: 15 men and 5 women with various intracerebral lesions were biopsied. Their average age was 62 years (range, 41-83 years). Preoperative planning was performed using computed tomography (CT) or magnetic resonance imaging (MRI) data provided by a radiological picture archiving and communication system (PACS) sent to the planning station. Planning was based on either MRI or CT in 14 and 4 cases, respectively, and a combination of both in 2 cases. RESULTS: The lesions had a mean maximal diameter of 42.97 mm (range, 5.8-109.8 mm). 19 lesions were supratentorial, 1 of those intraventricular, and 1 lesion was infratentorial, within the cerebellar peduncle and brainstem. During surgery, the samples were sent to neuropathological examination, and the procedure was completed after confirmation that pathological tissue was obtained. In 18 of 20 cases, definitive pathological tissue was harvested. Histopathology confirmed 8 glioblastomas, 1 oligoastrocytoma, 4 anaplastic astrocytomas, 1 astrocytoma, and 2 primary central nervous system lymphomas, as well as 1 encephalitis and 1 necrotic tissue of unknown origin. In 3 cases, including the case of necrotic tissue, there was no final diagnosis possible. Referencing the BrainLAB® navigation system and software-wizard guided sterile adjustment of the VarioGuide arm over the entry point took 5 to 10 minutes. The mean operation time was 49 minutes (range, 24-69 minutes) including the time until first neuropathological examination was completed. No adverse events occurred during or after the operation.

Surgical treatment of thoracic disc herniations via tailored posterior approaches.

We present clinical findings, radiological characteristics and surgical modalities of various posterior approaches to thoracic disc herniations and report the clinical results in 27 consecutive patients. Within an 8-year period 27 consecutive patients (17 female, 10 male) aged 30-83 years (mean 53 years.) were surgically treated for 28 symptomatic herniated thoracic discs in our department. Six of these lesions (21%) were calcified. In all cases surgery was performed via individually tailored posterior approaches. We evaluated the pre- and postoperative clinical status and the complication rate in a retrospective study. Nearly one half of the lesions (46.4%) were located at the three lowest thoracic segments. Clinical symptoms included back pain or radicular pain (77.8%), altered sensitivity (77.8%), weakness (40.7%), impaired gait (51.9%) or bladder dysfunction (22%). Costotransversectomy was performed in 8 patients, 1 lateral extracavitary approach, 2 foraminotomies, 15 transfacet and/or transpedicular approaches and 2 interlaminar approaches were used for removing the pathologies. After a mean follow-up of 38.6 months (3-100 months), complete normalization or reduction of local pain was recorded in 87% of the patients and of radicular pain in 70% of the cases, increased motor strength could be achieved in 55%, sensitivity improved in 76.2% and improvement of myelopathy was noted in 71.4%. Two patients suffered from postoperative impairment of sensory deficits, which in one case was discrete. The overall recovery rate within the modified JOA score was 39.5%. In 1 patient, two revisions were required because of instability and a persisting osteophyte, respectively. The rate of major complications was 7.1% (2/28). Surgical treatment of thoracic disc herniations via posterior approaches tailored to the individual patient produces satisfying results referring to clinical outcome. Posterior approaches remain a viable alternative for a large proportion of patients with symptomatic thoracic disc herniations.

Patient satisfaction and disability after brachial plexus surgery.

OBJECTIVE: Little is known about patient satisfaction and disability after brachial plexus surgery. Would patients undergo the procedure again, if they knew the current result beforehand? How do they rate their result and their disability? METHODS: Of 319 plexus patients who had undergone surgery between 1995 and 2005, 199 received a 65-item questionnaire. Measurement instruments included a new plexus-specific outcome questionnaire (Ulm Questionnaire) with categories of satisfaction, functionality, pain, comorbidities, and work; and the disability of the arm, shoulder, and hand questionnaire (DASH; scale, 0-100). RESULTS: Of 99 returned questionnaires, 70 were returned in a useful form for evaluation. The results of patients with C5-C6 lesions (21 of 70) are as follows: 90% (19 of 21) would undergo surgery again, 95% (20 of 21) were satisfied with the result, and 86% (18 of 21) subjectively improved. The mean DASH score was 41 (standard deviation [SD], 24). The results of patients with C5-C7 lesions (6 of 70) are as follows: 50% (3 of 6) were satisfied and would undergo surgery again, and 67% (4 of 6) improved. The mean DASH score was 46 (SD, 13). The results of patients with C5-T1 lesions (43 of 70) are as follows: 67% (29 of 43) would undergo surgery again, 81% (35 of 42) were satisfied, and 74% (32 of 43) reported improvement. The mean DASH score was 58 (SD, 26). The overall mean DASH score was 52 (SD, 26). Pain since the injury was prevalent in 86% of patients (60 of 70), back pain in 53%, and depression/anxiety in 21%. Fifty-two percent of those who worked before their injury (27 of 53 patients) remained unemployed or incapacitated for work. Forty-five percent of previous workers (24 of 53) returned to their former occupation. Occupational retraining was successful for 70% of patients (16 of 23). The mean duration until return to work was 9 months overall and 5 months for those who returned to their previous occupation. CONCLUSION: Eighty-seven percent of patients were satisfied with the results and 83% would undergo the procedure again. Despite a high satisfaction rate, patients remained considerably disabled, and half of the previous workers did not return to work. Occupational retraining is effective.

Skull metastasis of ampulla of Vater adenocarcinoma 5 years after Whipple operation: case report and literature review.

Skull metastases can occur with nearly all types of tumor. They frequently are asymptomatic, causing local swelling, which is usually painless and rarely leads to neurological dysfunction. Carcinoma of the ampulla of Vater is an uncommon tumor accounting for approximately 0.2% of all gastrointestinal malignancies, with an estimated incidence of less than 6 cases per 1,000,000 population per year. We report about an extremely rare case of a 54-year-old female patient with a right frontal skull metastases of an ampulla of Vater adenocarcinoma 5 years after pylorus-preserving pancreaticoduodenectomy. Literature review revealed only one published case of cranial bone metastases of carcinoma of the ampulla of Vater. To the best of our knowledge this is the first case report of skull metastases of ampullary adenocarcinoma after a symptom-free interval of 5 years after R0 resection of the primary tumor, and the second published case that involves the skull.

Success of simple sequestrectomy in lumbar spine surgery depends on the competence of the fibrous ring: a prospective controlled study of 168 patients.

STUDY DESIGN: Prospective controlled clinical study. OBJECTIVE: The aim of this prospective nonrandomized study is to evaluate the recurrence rate and the clinical outcome of patients undergoing sole sequestrectomy and compare them with a standard treatment group. SUMMARY OF BACKGROUND DATA: While performing microsurgical disc excision, extruded disc fragments and loosened or degenerated parts of the nucleus are removed. It is controversial whether this strategy is always necessary. Within the literature, there is only little information about the results of exclusive sequestrectomy. METHODS: Criteria for performing a sole sequestrectomy were a nonbulging disc and only small or medium perforations within the fibrous ring. According to these criteria, the authors recruited 90 patients for the sequestrectomy group. The control group was operated in standard microsurgical manner during the same time, including 84 patients. A detailed analysis of the actual pain status, the functional capacity (Hannover Activities of Daily Living Questionnaire, FFbH) and eventually additional spinal operations during the follow-up of 2 years was performed. RESULTS: Mean Funktionsfragebogen Hannover (FFbH) score at the follow-up was 76% in the sequestrectomy group and 77.6% in the control group. This difference is statistically not significant. There were 2 recurrences in the sequestrectomy group at the same level and 1 postoperative instability requiring a fusion procedure. In the control group, there were 2 recurrences and 1 secondary lateral spinal stenosis that led to reoperations. The competence of the fibrous ring influenced significantly the success of a simple sequestrectomy. CONCLUSION: The sole sequestrectomy group revealed similar results compared with the standard microdiscectomy group. There is a comparable low number of recurrences in both groups. This is probably caused by the consequent selection of patients for sequestrectomy according to well-defined criteria.

Degenerative cervical spinal stenosis: current strategies in diagnosis and treatment.

INTRODUCTION: Cervical spinal stenosis has become more common because of the aging of the population. There remains much uncertainty about the options for surgical treatment and their indications, particularly in cases of cervical myelopathy. METHODS: In order to provide guidance in clinical decision-making, the authors selectively reviewed the literature, according to the guidelines of the Association of Scientific Medical Societies in Germany. RESULTS: Cervical myelopathy is a clinical syndrome due to dysfunction of the spinal cord. Its most common cause is spinal cord compression by spondylosis at one or more levels. Its spontaneous clinical course is variable; most patients undergo a slow functional deterioration. Surgical treatment reliably arrests the progression of myelopathy and often even improves the neurological deficits. DISCUSSION: The available scientific data are too sparse to enable evidence-based treatment of cervical myelopathy. Early surgical intervention is often recommended in the literature. Controversy remains regarding the choice of the appropriate surgical procedure, but there is consensus on the suitable options for many specific clinical situations.

Degenerative lumbar spinal stenosis: current strategies in diagnosis and treatment.

INTRODUCTION: Although the aging of the population is causing a dramatic rise in the incidence of lumbar spinal stenosis, the indications and options for surgical treatment are not clearly defined. METHODS: In an attempt to aid clinical decision making, a selective literature review was conducted, taking into account the guidelines of the Association of the Scientific Medical Societies in Germany (AWMF). RESULTS: In degenerative lumbar spinal stenosis hypertrophy of the facet joints and yellow ligaments brings about constriction of the spinal canal, leading to back pain and activity-dependent lower limb symptoms (neurogenic claudication). If conservative treatment fails, an imaging study, usually magnetic resonance imaging, is required. In the case of severe symptoms the progressive underlying degeneration necessitates surgical treatment. Minimally invasive fenestration techniques are usually employed to decompress the spinal canal; in the presence of instability, fusion is indicated. DISCUSSION: Despite the proven superiority of surgery in the management of refractory lumbar spinal stenosis, there is a lack of evidence-based data regarding the different surgical treatment options. The evaluation of modern, minimally invasive techniques is thus difficult.

Nerve sheath tumor surgery: case-guided discussion of ambiguous findings, appropriateness of removal, repeated surgery, and nerve repairs.

In this article the authors attempt to raise awareness of the pitfalls and controversial issues in nerve tumor surgery. In a case-guided format, examples of ambiguous findings, inappropriate tumor removal, repeated surgery, and nerve repairs are provided. The authors also discuss the need to establish a correct diagnosis preoperatively and to avoid the erroneous identification of malignant peripheral nerve sheath tumors (MPNSTs). They emphasize that not all of the principles of soft tissue sarcoma treatment protocols are applicable to MPNST. A situation of repeated surgery for supposedly malignant tumor is described, and an outline of the indications for, and an approach to, repair after lesion removal is given.

Regulation of gene expression in intervertebral disc cells by low and high hydrostatic pressure.

Intervertebral disc structures are exposed to wide ranges of intradiscal hydrostatic pressure during different loading exercises and are at their minimum during lying or relaxed sitting and at maximum during lifting weights with a round back. We hypothesize that these different loading magnitudes influence the intervertebral disc (IVD) by alteration of disc matrix turnover depending on their magnitudes. Therefore the aim of this study was to assess changes in gene expression of human nucleus cells after the application of low hydrostatic pressure (0.25 MPa) and high hydrostatic pressure (2.5 MPa). IVD cells isolated from the nucleus of human (n = 18) and bovine (n = 24 from four animals) disc biopsies were seeded into three-dimensional collagen type-I matrices and exposed to the different loading magnitudes by specially developed pressure chambers. The lower pressure range (0.25 MPa, 30 min, 0.1 Hz) was applied with a recently published device by using an external compression cylinder. For the application of higher loads (2.5 MPa, 30 min, 0.1 Hz) the cell-loaded collagen gels were sealed into sterile bags with culture medium and stimulated in a newly developed water-filled compression cylinder by using a loading frame. These methods allowed the comparison of loading regimes in a wide physiological range under an equal three-dimensional culture conditions. Cells were harvested 24 h after the end of stimulation and changes in the expression of genes known to influence IVD matrix turnover (collagen-I, collagen-II, aggrecan, MMP1, MMP2, MMP3, MMP13) were analyzed by real-time RT-PCR. A Wilcoxon signed-rank test(1) and a Wilcoxon 2-sample test(2) were performed to detect differences between the stimulated and control samples(1) and differences between low and high hydrostatic pressure(2). Multiple testing was considered by adjusting the p value appropriately. Both regimes of hydrostatic pressure influenced gene expression in nucleus cells with opposite tendencies for the matrix forming proteins aggrecan and collagen type-I in response to the two different pressure magnitudes: Low hydrostatic-pressure (0.25 MPa) tended to increase collagen-I and aggrecan expression of human nucleus cells (P < 0.05) but only to a small degree. High hydrostatic pressure (2.5 MPa) tended to decrease gene expression of all anabolic proteins with significant effects on aggrecan expression of nucleus cells (P = 0.004). Low hydrostatic pressure had no influence on the expression of matrix metalloproteinases (MMP1, MMP2, MMP3 and MMP13). In contrast, high hydrostatic pressure tended to increase the expression of MMP1, MMP3 and MMP13 of human nucleus cells with high individual-individual variations. The decreased expression of aggrecan (P = 0.008) and collagen type II (P = 0.023) and the increased MMP3 expression (P = 0.008) in response to high hydrostatic pressure could be confirmed in additional experiments with bovine nucleus cells. These results suggest that hydrostatic pressure as one of the physiological stimuli of the IVD may influence matrix turnover in a magnitude dependent way. Low hydrostatic pressure (0.25 MPa) has quite small influences with a tendency to anabolic effects, whereas high hydrostatic pressure (2.5 MPa) tends to decrease the matrix protein expression with a tendency to increase some matrix-turnover enzymes. Therefore, hydrostatic pressure may regulate disc matrix turnover in a dose-dependent way.

Role of intraoperative neurophysiology in primary surgery for obstetrical brachial plexus palsy (OBPP).

OBJECTIVE: Management of conducting neuroma-in-continuity in primary surgery for obstetrical brachial plexus palsy (OBPP) is still discussed controversially. We present our experience with intraoperative neurophysiological recordings in the management of lesions in continuity in OBPP. METHODS: A series of ten children with lesions in continuity of the upper brachial plexus is presented. Due to recordable compound nerve action potentials (CNAPs) and muscle response to motor stimulation across the neuroma, five children underwent external neurolysis of neuroma only (neurolysis group). Due to lack of recordable CNAPs or muscle response, resection of neuroma and interpositional nerve grafting were performed in another five children (resection and grafting group). Functional recovery after at least 30 months of follow-up was assessed. RESULTS: There was a marked difference in functional recovery between the neurolysis and the resection and grafting group. Especially, recovery of shoulder function was disappointing after external neurolysis of conducting neuroma-in-continuity. At the end of follow-up, results of shoulder and elbow function after resection of neuroma followed by interpositional nerve grafting were better without exception. CONCLUSION: Intraoperative neurophysiological recordings face certain difficulties when used in small children with OBPP. Due to overoptimistic assessment of prognosis after intraoperative CNAP recordings and motor stimulation, the functional results after neurolysis of conducting neuroma-in-continuity are disappointing. Resection of neuroma-in-continuity, conducting or not, offers the best opportunity for maximal functional recovery of the compromised upper limb in OBPP. The role of intraoperative neurophysiological techniques should be confined to the diagnosis of root avulsions.

A three-dimensional collagen matrix as a suitable culture system for the comparison of cyclic strain and hydrostatic pressure effects on intervertebral disc cells.

OBJECT: To study intervertebral disc cell mechanobiology, the authors developed experimental systems that allow the application of cyclic strain and intermittent hydrostatic pressure (IHP) on isolated disc cells under equal three-dimensional (3D) culture conditions. The purpose of the study was to characterize disc cell proliferation, viability, morphology, and gene expression in 3D collagen matrices. METHODS: The effects of cyclic strain (1, 2, 4, and 8% strain; 1 Hz) and IHP (0.25 MPa, 0.1 Hz) on gene expression (real-time polymerase chain reaction) of anabolic and catabolic matrix proteins were investigated and compared with those derived from mechanically unstimulated controls. Intervertebral disc cells proliferated in the collagen gels (mean viability 91.6%) and expressed messenger RNA for collagen I, collagen II, aggrecan, matrix metalloproteinase (MMP)-2, and MMP-3. Morphologically, both spindle-shaped cells with longer processes and rounded cells were detected in the collagen scaffolds. Cyclic strain increased collagen II and aggrecan expression and decreased MMP-3 expression of anulus fibrosus cells. No significant difference between the four strain magnitudes was found. Intermittent hydrostatic pressure tended to increase collagen I and aggrecan expression of nucleus cells and significantly decreased MMP-2 and -3 expression of nucleus cells, whereas aggrecan expression of anulus cells tended to decrease. CONCLUSIONS: Based on these results, the collagen matrix appeared to be a suitable substrate to apply both cyclic strain and IHP to intervertebral disc cells under 3D culture conditions. Individual variations may be influenced by the extent of degeneration of the disc specimens from which the cells were isolated. This experimental setup may be suitable for studying the influence of degeneration on the disc cell response to mechanical stimuli.

Treatment and outcome of aneurysmal subarachnoid haemorrhage in the elderly patient.

From January 1999 to May 2003, 316 aneurysms were treated, among them 40 patients (12.7%) over 65 years with subarachnoid haemorrhage (SAH). The results of this sub-group are presented. Mean age was 71 years (range 65-83 years), 40% of the patients were in (Hunt & Hess) grade I-III and 60% grade IV-V. Eighty-five percent of the aneurysms were located in the anterior circulation (35% ACom aneurysms). Nineteen aneurysms were coiled (all basilar tip and small-based ACom aneurysms), two among them subsequently clipped after coil compaction, 18 were initially clipped (most of MCA and all broad-based ACom aneurysms), two wrapped and one trapped. A total of 66.7% of the patients with coiled and 60.0% with clipped aneurysms had been hospitalized in poor condition (Hunt & Hess IV-V). The average follow-up period was 16 months. Overall, 35% of patients fully recovered, 5% returned to normal activity with some deficit, 33% remained dependent and 27% died. All seven patients with MCA aneurysms and intracerebral haematoma were clipped, but died or remained vegetative. Ten of 17 coiled patients (58.8%) had a favourable outcome, compared to 4/11 (36.4%) in the clip group, but two primarily coiled aneurysms rebled due to coil compaction. The outcome is dependent on the primary Hunt & Hess grade. A total of 48.5% of SAH patients without intracerebral bleeding fully recovered, even patients in poor primary grade. Additional intracerebral haemorrhage is linked to a bad outcome. As primary procedure, the less traumatic coiling seems to be superior to clipping primarily. Better Hunt & Hess grades have a statistically significant chance for a promising outcome.

Spinal hematoma unrelated to previous surgery: analysis of 15 consecutive cases treated in a single institution within a 10-year period.

STUDY DESIGN: Retrospective clinical study. OBJECTIVES: To determine characteristics, treatment methods, and outcome in an institutional series of patients with spinal hematoma not related to previous surgery. METHODS: The charts of all patients with spinal hematoma treated in our institution between January 1993 and December 2002 were reviewed and analyzed with regard to location and extension of the hematoma, duration of symptoms, neurologic status, diagnostic measures, therapy, and outcome. RESULTS: Fifteen patients were identified with spinal hematomas not caused by previous spine surgery. There were 11 women and 4 men. One hematoma was located subdurally and another intramedullary. All other hematomas were extradural, with 10 spontaneous bleedings. Eight hematomas were located in the cervical, two in the cervicothoracic, and three in the thoracic region. Two others were situated in the lumbar spine. Mean extension was 4.7 segments (range, 2-8 segments). Mean interval between onset of symptoms and surgery was 18 hours (range, 8-48 hours) for 12 patients; in 2 cases, diagnosis was made after 17 and 36 days, respectively, and then treated by surgery. One patient was treated without operation. Operative treatment was accomplished in all cases by hemilaminectomy and/or interlaminar fenestration and hematoma evacuation, in those cases with a larger extension of extradural hematoma by an alternating hemilaminectomy, thus reducing the risk of postoperative instability. There was no recurrence. No correlation between time to surgery and outcome was found in this study group, but there was a strong correlation between initial neurologic status and outcome after surgery. CONCLUSIONS: Nonsurgical derived spinal hematomas are rare. In this series, most cases were spontaneous and located in the cervical or cervicothoracic region producing severe neurologic deficit and pain. Treatment should be surgical evacuation in the majority. As most hematomas are of great extension, alternating hemilaminectomy suffices for evacuation of extradural hematomas and supports the stability of the spinal segments. Outcome is highly dependent from initial neurologic status.

Spinal tumors in coexisting degenerative spine disease--a differential diagnostic problem.

The clinical presentation of spinal tumors is known to vary, in many instances causing a delay in diagnosis and treatment, especially with benign tumors. Neck or back pain and sciatica, with or without neurological deficits, are mostly caused by degenerative spine and disc disease. Spinal tumors are rare, and the possibility of concurrent signs of degenerative changes in the spine is high. We report a series of ten patients who were unsuccessfully treated for degenerative spine disease. They were subsequently referred for operative treatment to our department, where an initial diagnosis of a tumor was made. Two patients had already been operated on for disc herniations, but without long-lasting effects. In eight patients the diagnosis of a tumor was made preoperatively. In two cases the tumor was found intraoperatively. All patients showed radiological signs of coexisting degenerative spine disease, making diagnosis difficult. MRI was the most helpful tool for diagnosing the tumors. A frequent symptom was back pain in the recumbent position. Other typical settings that should raise suspicion are persistent pain after disc surgery and neurological signs inconsistent with the level of noted degenerative disease. Tumor extirpation was successful in treating the main complaints in all but one patient. There was an incidence of 0.5% of patients in which a spinal tumor was responsible for symptoms thought to be of degenerative origin. However, this corresponds to 28.6% of all spine-tumor patients in this series. MRI should be widely used to exclude a tumor above the level of degenerative pathology.