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.

Image guided aneurysm surgery in a Brainsuite® ioMRI Miyabi 1.5 T environment.

OBJECTIVE: Current literature only gives sparse account of aneurysm surgery in an intraoperative MRI environment. After installation of a BrainSuite(®) ioMRI Miyabi 1.5 T at our institution the aim of the present preliminary study was to evaluate feasibility, pros and cons of aneurysm surgery in this special setting. MATERIAL AND METHODS: Since February 2009, during a 3 months period we performed elective image guided aneurysm surgery in 4 ACM and 1 ACOM aneurysm (four patients) in this ioMRI setting. The patients' heads were rigidly fixed in the Noras 8-Channel OR Head Coil. Our imaging protocol included MP-RAGE, T2-TSE axial, TOF-MRA and diffusion-/perfusion-imaging immediately before surgery and after clip application. Presurgical 3D-planning was performed using the iPlan®-Software. RESULTS: All five aneurysms were operated without temporary clipping. There were no intra- or postoperative complications. Patient positioning and head fixation with the integrated Noras Head Clamp was feasible, but there were significant limitations particularly with regard to more complex approaches and patient physiognomy. Image quality especially TOF-MRA was good in 4, insufficient in 1 aneurysm. Presurgical planning especially vessel extraction from TOF-MRA was possible but certainly needs significant future improvement. Diffusion- and perfusion weighted examinations yielded good image quality. CONCLUSION: Our limited experience is encouraging so far. Further improvement particularly concerning flexibility of patient positioning and presurgical 3D-planning for vascular procedures is most necessary. As a future perspective image guided aneurysm surgery in an ioMRI-environment may be helpful especially in complex aneurysms and provide neurosurgeons and neuroanaesthesiologists with additional information about cerebral haemodynamics and perfusion pattern in the vascular territory distal to the target vessel.

[The endoscopic management of the cubital tunnel syndrome--an anatomical study and first clinical results]. / Die endoskopische Dekompression des Kubitaltunnelsyndroms--Anatomische Grundlagen und erste klinische Ergebnisse.

Besides the carpal tunnel syndrome, the cubital tunnel syndrome (CuTS) represents the second most frequent nerve entrapment syndrome. The current gold standard for surgical therapy consists of simple open decompression. Recently, an endoscopic procedure involving long-distance decompression of the ulnar nerve has been developed and this is the topic of the present study. The first part of this paper describes preliminary anatomic investigations on 22 cadaver arms. In every sample we observed a thickening of the submuscular membrane between the heads of the flexor carpi ulnaris (FCU) which surrounds the ulnar nerve. This was especially the case for the first 10 cm from the medial epicondyle In the second part we report our experiences with this endoscopic decompression procedure in 36 patients. With this endoscopic decompression we achieved good to very good results according to the Bishop classification in 28 patients (78%). On the basis of anatomic considerations and our current experience, the endoscopic procedure seems to represent a promising alternative to simple decompression.

Intraneural perineuriomas; a rare entity. Clinical, surgical and neuropathological details in the management of these lesions.

OBJECTIVE: Perineuriomas are rare benign peripheral nerve sheath tumors, which have only been included in the WHO classification system since 2000. They are divided into intraneural perineuriomas and soft tissue tumors. Intraneural perineuriomas were previously known as localized hypertrophic neuropathies. Because of their rarity there are only case reports in the literature. METHODS: Between 1992 and 2006 surgery was performed on four patients suffering from intraneural perineuriomas in our hospital. All patients were males, aged five, ten, twenty and twenty-nine years old. One of the tumors occurred in the ulnar nerve, one in the common peroneal part of the sciatic nerve and two of them in the radial nerve. In a retrospective study the clinical, electrophysiological and imaging data of the patients was analyzed. Two of these patients had previously been treated with decompression and neurolysis of the nerve for the suspicion of a nerve compression syndrome. Revisions were necessary following progressive neurological deterioration postoperatively. Explorations of the nerves showed nerve tumors. The tumors were resected and nerve grafting was performed. CONCLUSIONS: These tumors tend to affect the nerves of the upper extremities in children or young adults. The predominant symptom is a slow-progressive paralysis. Two of the four patients showed a partial improvement of their motor and sensorial nerve deficits in the long-term follow-up following complete tumor resection and interpositional autologous nerve grafts. No relapse could be observed. In cases of slow-progressive neurological deficits of a peripheral nerve in young patients the differential diagnosis should include the intraneural perineuriomas.

Neurosurgical management of previously coiled recurrent intracranial aneurysms.

OBJECTIVE: Endovascular treatment of cerebral aneurysms with detachable coils has proven to be a save and effective treatment. But long-term recurrence due to aneurysm regrowth or coil compaction has been reported in up to thirty percent of cases. Therefore a growing number of previously coiled aneurysms have to be retreated by coiling or, in some circumstances, by clipping. We present a consecutive series of ten patients who underwent surgical clipping for recurrent aneurysms after primary coil embolization. METHODS: During a 4-year period ten patients with intracranial aneurysms previously treated by coil embolization underwent surgery for clipping of recanalized aneurysms. All aneurysms were located in the anterior circulation (internal carotid artery [ICA], 2; middle cerebral artery [MCA], 3; anterior communicating artery [AcomA], 5). Clinical data and imaging studies of the patients were analyzed retrospectively. RESULTS: All recurrences were detected by routine control angiograms within a median period of 14 months after primary treatment. In three aneurysms treated for SAH dense arachnoid scarring around the aneurysm sac was noted. In four cases, coils were found intraoperatively to be extruding through the aneurysm sac into the subarachnoid space. Each aneurysm could be clipped without affecting the perfusion of the parent vessel. In one patient the aneurysm sac including the coil package was resected. In one patient one of the central anteromedial arteries was injured during dissection due to dense arachnoid scarring because of prior SAH. As a consequence infarction of the head of the caudate nucleus without neurological compromise was observed on follow-up CT scans. Another patient developed transient aphasia due to vasospasm in the early postoperative period with complete restitution. In the end all patients had an uneventful recovery. Removal of the coil package was not necessary in most cases. Clipping of the aneurysm neck was possible even in cases with coil dislocation into the parent vessel. CONCLUSION: Clipping of previously coiled aneurysms is a unique problem for vascular neurosurgeons. In most cases clipping is feasible. Clipping should still be considered as a definite treatment option in previously coiled recurrent aneurysms. Results in this small series were good.

[Neurogenic thoracic outlet syndrome. Long-term results of supraclavicular decompression]. / Neurogenes Thoracic-outlet-Syndrom. Langzeitergebnisse der supraklavikulären Dekompression.

OBJECTIVES: Neurogenic thoracic outlet syndrome (TOS) is one of the most controversial entrapment syndromes of the upper extremity. There are two different surgical approaches for its primary surgical treatment: supraclavicular decompression and transaxillary first rib resection. The aim of this study was to evaluate long-term results and surgical risks of the former. METHODS: This retrospective long-term study examines a series of 50 supraclavicular decompressions in 45 patients. Follow-up was for at least 24 months. All patients were reexamined regularly in nonstandardized fashion. Finally, each patient underwent a telephone interview with a standardized questionnaire. RESULTS: There was a significant deterioration of primary results during follow-up. About 30.0% of cases worsened within 24 months after operation. In the long run, about 80.0% of cases showed improvement of symptoms (26.0% excellent, 36.0% good, 18.0% moderate). The complication rate was 4.0%. CONCLUSION: Due to secondary deterioration of treatment during follow-up, only long-term studies are suited for the examination of neurogenic TOS. Results after supraclavicular decompression are satisfactory, and the complication rate is low.

Percutaneous transarticular atlantoaxial screw fixation using a cannulated screw system and image guidance.

In 2000 a cannulated screw stabilization system for posterior cervical instrumentation was introduced in our department for use in complex cervical fixation procedures. A special feature of the system is the use of thin Kirschner wires for drilling the screw paths and then placing the self-drilling, cannulated screws securely over the wires. Percutaneous application of C1-C2 transarticular screws is possible through tubes. An optional "atlas-claw" provides additional stability in cases of C1-C2 stabilization. 17 patients (10 female, 7 male, mean age 60 years) with complex cervical disorders and instability of different origin were stabilized using the Neon System (Ulrich Co., Ulm, Germany). Pathology included atlantoaxial instability based on rheumatoid arthritis (n = 12), odontoid fracture (n = 4) and os odontoideum mobile (n = 1). Computed navigation (STN 4.0, Zeiss or vector vision spine, brain lab) was used in 14 cases. Transarticular C1-C2 screw fixation was performed in 14 cases (4 patients with direct C1 massa lateralis screw fixation), craniocervical fixation (C0-C2/C3) was done in 3 patients. Percutaneous application of the C1-C2 screws was used in 7 patients. Atlas claws were applied in 8 patients. There was one medial perforation of a C2 pedicle wall and one malposition of the screw in C2 without reaching the lateral mass of C1. After a mean follow-up of 9 months there were no hardware failures and stable fusion in those cases followed after 12 months or more. Clinical results were excellent or good in 14/16 patients. Cannulated screws are an effective alternative in complex stabilization procedures of the cervical spine. The presented system is technically comfortable and allows safe percutaneous screw application as well as inclusion of computed navigation with high accuracy.

First clinical experiences with a new cervical fixation device - technical report.

In a first clinical series of ten patients the new cervical fixation device StarLock trade mark (Synthes, Umkirch, Germany) was implanted.[nl]Characteristics of the device are deep threaded screws with higher pullout resistance and a high angular tolerance while inserting the rods thus simplifying the implantation.[nl]62 lateral mass screws in ten patients were inserted. In 2 cases placement of screws was insufficient (3.2 %) because of surgical difficulties not attributable to the system technique.[nl]In all other cases a radiologically proven stabilization was created. [nl]Due to the high angular tolerance of the screw clamps bending of rods is simplified, especially in cases of longer constructs, and shortens the operation time.[nl]The design of the StarLock trade mark system allows an easy application of computer-navigated placing of transpedicular screws.[nl]This new cervical fixation device is easy to handle and simplifies rod application especially in longer constructs.

[Management of obstetrical brachial plexus palsy--own experience with the primary operative technique]. / Management bei geburtstraumatischen Läsionen des Plexus brachialis - Eigene Erfahrungen mit der primären operativen Behandlung -

Obstetrical brachial plexus palsy occurs at a frequency of 0.6 to 2.5 per 1000 births. 80 to 95% of these lesions recover spontaneously. If spontaneous recovery does not occur within the first six months of life, investigations like electrophysiology, and CT-myelography and surgical exploration of the brachial plexus are recommended. During the last ten years 73 children with obstetrical brachial plexus lesions were examined in our department. 29 newborns underwent surgery on the brachial plexus. In 20 out of 29 children nerve root avulsions were diagnosed preoperatively. We performed in 16 cases nerve grafting after neuroma excision, in four cases nerve grafting combined with neurotization, in seven cases external or internal neurolysis, and in the remaining two cases neurotization and plexo-plexal transfer, respectively. The children were followed up between 18 and 50 months (range 27 months) in 18 cases. Elbow function according to Gilbert scale achieved one half of the patients four to five points and the other half two to three points. We found shoulder function with abduction between 45 degrees to 128 degrees and external rotation in 61% (Grade II to V, according to Gilbert scale). In 31% hand function showed Grade III and IV (Gilbert and Raimondi scale). We recommend decision for surgery at the age of six months. Operation should be planned between six to nine months of life. In addition, physical therapy and options including muscle transfers and orthopaedic procedures must be available to ensure the optimal outcome for these children.