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.

Experience with two different techniques of percutaneous dilational tracheostomy in 54 neurosurgical patients.

We report 54 patients with critical neurosurgical diseases (16 females, 38 males, age 21-84 years, mean 63.2 years) who were treated with bedside percutaneous dilational tracheostomy (PDT) because of respiratory insufficiency due to their cerebral disease. Bronchoscopically guided PDT was performed after stabilisation of the acute stage of neurosurgical disease. In 15 cases, Ciaglia's multiple dilation technique was used, and in 39 patients the dilational forceps technique according to Griggs was performed. In 14 cases (five Ciaglia's method, nine Griggs technique), intracranial pressure (ICP) was monitored throughout the procedure. Fifty-two procedures were completed. In two cases, PDT had to be aborted because of inability to puncture the trachea. No death occurred. There was a total complication rate of 16.7%, including the aborted procedures, with 3.7% of the complications classified as severe. No increase in ICP was noted. We conclude that bedside PDT, especially with the Griggs system, is safe and effective if done under bronchoscopic control. With the standard narcotic regimen used in our patients, no increase in ICP occurred.