Treatment of very large cranial defects with individually shaped polypropylene polyester knitwear prostheses: a series of 11 cases.

BACKGROUND: Very large cranial defects are not very common in neurosurgical practice and there is not any widely acknowledged standard of their treatment. One of the useful methods in such cases is individual forming of polypropylene-polyester knitwear. Such material was used in the past but before 2008 it was available only as standardized plates. Currently, it can be also produced as individually-shaped implants. The authors give their definition of very large cranial defects and present their experience with this cranioplastic method in such defects. METHODS: The authors collected data on 11 cases of patients with very large cranial defects, from a total of 156 cases, operated on in 5 Polish neurosurgical departments. The necessary implants were prepared for individual patients according to the data provided by a computed tomography examination and with the use of computer aided machining. RESULTS: All defects were larger than 120 cm2 (129 to 178 cm2) and exceeded 1/4 of the calvaria area. Patients were operated between 2008 to 2012. In all patients, a very good aesthetic result and correct skull reconstruction was achieved. The follow-up time in all cases exceeded 1 year and reached 4 years in one case. No complications were observed. CONCLUSIONS: Individually pre-shaped polypropylene-polyester knitwear prostheses are a good alternative to the existing cranioplasty methods, particularly in very large cranial defects.

Chronic Subdural Hematoma (CSH) is Still an Important Clinical Problem. Analysis of 700 Consecutive Patients.

BACKGROUND: Chronic subdural hematoma (CSH) is still an important neurosurgical problem and the number of patients increases despite the progress in early diagnosis of cerebral lesions. METHODOLOGY: We analyzed a group of 700 consecutive patients treated in neurosurgical departments for CSH. Clinical state on admission was evaluated according to the Markwalder scale, all patients had CT studies and were operated using craniotomy or burr holes with closed system drainage techniques. RESULTS: More than 50% had extensive intracranial bleeding, almost half of the patients were treated with oral anticoagulants. The patients with extensive fresh bleeding were in significantly worse states on admission and were treated by craniotomy and external capsulectomy (42%). All the others had burr holes and closed system drainage of the subdural space. Results of treatment were acceptable, 2% died, and 1.5% remained vegetative, due to massive hemorrhage and severe neurological deficits on admission. CONCLUSIONS: Despite a progress in diagnosis, CSH still remains an often cause of severe intracranial complications. The rising number of occurrences of this lesion is strictly connected with a wide use of oral anticoagulants. Surgical removal of CSH still remains the best type of treatment for such lesions.

Vertebroplasty (PVP) is effective in the treatment of painful vertebral hemangiomas.

We assessed the results of percutaneous vertebroplasty treatment of painful vertebral hemangiomas in 110 patients, with a three years follow-up. 110 patients with painful vertebral hemangiomas were treated by percutaneous vertebroplasty. The patients were diagnosed by MRI and observed for 3 years after surgery. Visual Analog Scale was used to assess the level of pain. Pain significantly diminished in all patients, 90% were free of pain for three years after augmentation. In 10% some pain appeared after 1 year, but less intensive than before surgery. 3 years after vertebroplasty 90% of patients were free of pain. No complications of PVP were observed. In 3 patients extravertebral leakage was noted with no clinical symptoms. PVP is highly effective in the treatment of painful vertebral hemangiomas. The method is safe, produce minimal complications and eliminates, or highly reduces pain for a long time period.

Keyhole Surgery of Pineal Area Tumors - Personal Experience in 22 Patients.

BACKGROUND: Pineal area tumors are challenging for surgery due to their location. However, the removal of the lesion is critical for further treatment and survival of the patients. MATERIAL AND METHODS: 22 patients with pineal area tumors were surgically treated via keyhole medial suboccipital craniotomy and supracerebellar midline approach All the patients were operated in the sitting position with the use of operating microscope and microsurgical technique. RESULTS: All patients survived surgery in a perfect condition, and no one patient worsened after surgery. No complications due to the sitting position were noted. CONCLUSIONS: Surgical removal of pineal area tumors via small suboccipital craniotomy is safe and with the use of microsurgical techniques the results of surgical treatment are excellent. The sitting position of the patients gives a better view to the surgeon. We did not observe any intraoperational complications due to the sitting position.

Complications of percutaneous vertebroplasty: An analysis of 1100 procedures performed in 616 patients.

Percutaneous vertebroplasty (PVP) is a minimally invasive procedure widely used for the treatment of pain due to vertebral fractures of different origins-osteoporotic, traumatic, or neoplastic. PVP is minimally invasive, but the complications are not rare; however, they are in most cases not significant clinically. The most frequent is cement leakage, which can occur onto veins, paravertebral soft tissue, into the intervertebral disk, or to the spinal canal, affecting foraminal area or epidural space. We analyzed results of treatment and complications of vertebroplasty performed with the use of polimethylomethylacrylate cement (PMMA) on 1100 vertebrae, with a special regard to the severity of complication and eventual clinical manifestation. One thousand one hundred PVP were analyzed, performed in 616 patients. There were 468 (76%) women and 148 men (24%), 24 to 94-year old, mean age 68 years. From 1100 procedures, 794 treated osteporotic and 137 fractures due to malignant disease, 69 PVP were made in traumatic fractures. One hundred patients had painful vertebral hemangiomas. Seven hundred twenty-six (66%) lesions were in thoracic, and 374 (34%) in lumbar area. Results of treatment were assessed using 10 cm Visual Analogue Scale (VAS) 12 hours after surgery, 7 days, 30 days, and then each 6 months, up to 3 years. Before surgery all patients had significant pain 7 to 10 in VAS scale, mean 8.9 cm. Twelve  hours after surgery 602 (97.7%) reported significant relief of pain, with mean VAS of 2,3 cm. Local complications occurred in 50% of osteoporotic, 34% of neoplastic, 16% of traumatic fractures, and 2% of vertebral hemangiomas. The most common was PMMA leakage into surrounding tissues-20%; paravertebral vein embolism-13%; intradiscal leakage-8%; and PMMA leakage into the spinal canal-0.8%. Results of treatment did not differ between patients with and without any complications. From 104 patients who had chest X-ray or CT study performed after surgery, pulmonary embolism was noted in 2 patients, but without any clinical symptoms. Only 1 patient-with PMMA leakage into the spinal canal required surgical decompression In conclusion, PVP is effective in decreasing the level of pain in compression vertebral fractures. Complications occur in almost half of the patients but in more than 95% of them do not produce any clinical symptoms.

Treatment of multiple osteoporotic vertebral compression fractures by percutaneous cement augmentation.

PURPOSE: Vertebral compression fractures cause significant pain and some patients are debilitated by the pain due to the fracture. Conventional surgery carries a high risk and has a poor outcome. Vertebroplasty is a minimally invasive surgical procedure, which in vertebral fractures restores stability and diminishes pain. The aim of the study was to analyse the effectiveness and safety of vertebroplasty in multiple vertebral compression fractures with a 24-month follow-up. METHODS: Vertebroplasty was performed in 160 patients with multiple osteoporotic compression fractures under local anaesthesia, using a unilateral transpedicular approach. The level of pain was assessed according to a 10-cm visual analogue scale. The patients were observed for 24 months after surgery. RESULTS: Vertebroplasty significantly diminished the level of pain in 90% of patients, and half of them were free of pain within 12 hours after surgery. Only 4% of the patients did not benefit from this type of treatment. During the 24-month follow-up these results changed only slightly, and after two years almost 80% still benefited, while the number of unsatisfactory results changed from 6 to 9%. No serious clinical complications were noted; in three patients new fractures appeared during the two year observation period. CONCLUSIONS: Vertebroplasty should be seriously taken into account as a primary method of treatment in patients with multiple osteoporotic vertebral compression fractures.

Reconstruction of cranial defects with individually formed cranial prostheses made of polypropylene polyester knitwear: an analysis of 48 consecutive patients.

This article presents a new method of cranioplasty in which polypropylene polyester knitwear was used as the filling material. The basis for prosthesis shaping was a three-dimensional model of the defect made according to the patient's CT scans. Previously, such material has never been a subject of computer-aided design and computer-aided manufacturing (CAD/CAM) individual forming. The process of the prosthesis design included CT bone scans and mold preparation for each patient. Such prostheses were implanted in 48 patients with cranial defects. The total number of prostheses applied was 51. The follow-up time was at least 6 months up to 36 months. The group of treated patients is described here, and sample pictures are shown to illustrate the results. The smallest defect had a size of 15 cm(2); the biggest, 178 cm(2). The coverage and the aesthetic results were very good in all cases. Two patients had postoperative complications. The cranioplastic solution described here is a valuable addition to the existing reconstructive methods, because of the low cost of the implant, the ease of its adjustment to the shape of the defect, and the short time of preparation.

Early and long-term outcomes of vertebroplasty for single osteoporotic fractures.

BACKGROUND AND PURPOSE: Percutaneous vertebroplasty (PVP) is a minimally invasive vertebral augmentation procedure for the treatment of recent, osteoporotic vertebral compression fractures. The aim of the study was to determine the early and late outcomes of PVP for osteoporotic vertebral compression fractures. MATERIAL AND METHODS: We prospectively assessed outcomes of PVP in 200 patients with single, osteoporotic vertebral compression fracture. Follow-up assessment was made 12 hours after surgery as well as after 7 days, 30 days, 3 months, 6 months, and 1 year after surgery. A subgroup of 80 patients was evaluated also 2 years after PVP. A 100-mm visual analogue scale of pain was used for outcome measurement. RESULTS: Twelve hours after PVP, very significant relief of pain was obtained in 85% of patients; on the 7th and 30th day a very good result of treatment was noted in 96%. The same result was noted in 92% of patients at the 6th month, and in 90% of patients at the 12th month. Among the 80 patients followed for 2 years, 3 patients reported recurrence of pain and were subsequently diagnosed with new osteoporotic fractures. CONCLUSIONS: Percutaneous vertebroplasty is a minimally invasive method of treatment for fresh osteoporotic fractures, which provides a significant and sizeable reduction of pain in the short as well as long term after surgery. Complete relief of pain was noted 12 hours after PVP in 94% of patients, and was noted in 90% two years after treatment. Despite some literature data suggesting no beneficial effect of PVP, it can be concluded that PVP is the most effective and the safest method for fresh vertebral compression fracture treatment.