Neuromodulation in the treatment of postoperative epidural fibrosis: comparison of the extent of epidural fibrosis and the effect of stimulation.

The goal was to prove that when a cohort of patients is chosen precisely, dorsal column stimulation provides significant improvement to quality of life. We studied a cohort of 50 patients with the history of failed back surgery syndrome coupled with epidural fibrosis (EF). A percutaneous implantation technique was used in each of the 50 patients. The study group was composed of 20 women and 28 men aged 26-67 years (mean age 49). A prospective observational questionnaire-based study was used. According to the methods, Ross's classification was adjusted to four degrees of scar size for our study objective. Despite this adjustment, it was not possible to statistically evaluate our research, due to very similar results in Groups I, III and IV. Patients without epidural fibrosis were assigned to Group 0, and patients with EF of different ranges were assigned to Group 1. The mean change in visual analogue scale DeltaVAS after our division into Group 0 was 4.82; for Group 1 it was 6.13. Evaluation of EF and DeltaVAS correlation by paired t-test shows a statistically higher effect of spinal cord stimulation (SCS) in the epidural fibrosis group, compared to group 0 without postoperative epidural fibrosis (p=0.008). The extent of epidural fibrosis is an important factor for Failed back surgery syndrome (FBSS). FBSS is the basis for the existence of neuropathic pain after lumbar spinal surgery. There is clear evidence of a correlation between patients with epidural scar formation on MR scan and the effect of dorsal column stimulation.

Electrode movement prevention - an animal model.

Electrode migration is the most common complication of spinal cord stimulation (SCS). The problem of longitudinal migration has already been solved, but lateral migration remains the most common current complication. The present article describes new electrodes fixation opportunities for the reduction of lateral migration in SCS. The pig was chosen as an animal model to illustrate a new protocol of electrode fixation for the control of lateral and longitudinal migration. The displacement of the electrode was measured using two different optical methods: the digital image stereo-correlation and the digital image processing methods. Fixation with two anchors has always considerably reduced electrode displacement and when fixation is done with two anchors and a loop then lateral migration is reduced by 62.5 % and longitudinal migration is reduced by 94.1 %. It was shown that the results are significantly different at the alpha=0.001 significance level. Based on a statistical evaluation it is possible to state that the differences between experimental results obtained for three different protocols of lead fixation are statistically significant and we can recommend the new fixation method for common practice.

[Endoscopic endonasal treatment of cerebrospinal fluid leak caused by clival fracture--a case report]. / Endoskopické endonazální osetrení nasální likvorey pri zlomenine klivu--kazuistika.

INTRODUCTION: Clivus is a central structure of the skull base located in the vicinity of the brainstem and vital brain vessels. Clival fractures are usually caused by a high-energy trauma. Cerebrospinal fluid leak is one of the most common complications. CASE REPORT: A middle-aged male sustained a mild head trauma, followed by a nasal cerebrospinal fluid leak. CT scan revealed the massive pneumocephalus and the fracture of the clivus in the posterior wall of the sphenoidal sinus. We performed an endoscopic endonasal surgery to seal the defect. DISCUSSION: Pneumatization of a sphenoidal sinus shows high variability. In the presented case, extreme pneumatization of the sinuses was combined with the gracile clivus, which was the predisposing factor for fracture. Traumatic cerebrospinal fluid leak carries the risk of intracranial hypotension and meningitis. Microscopic transseptal management is the classical surgical approach, while endoscopy provides the modern miniinvasive option. CONCLUSION: Endoscopic endonasal treatment of traumatic cerebrospinal fluid leak is the treatment of choice for the clival fractures.

Dopamine 2 and somatostatin 1-5 receptors coexpression in clinically non-functioning pituitary adenomas.

This study investigated quantitated expression of dopamine 2 receptor (D2R) and somatostatin receptors of the five types (SSTR1-SSTR5) in a large series of clinically non-functioning pituitary adenomas (CNFAs). Co-expression of these receptors in individual adenomas was studied as well as correlation between receptor types. Adenoma tissue from 198 patients who underwent surgery for CNFAs was analyzed by immunohistochemistry and quantitative real-time PCR. D2R and SSTR1-3 mRNA was expressed in all 198 adenomas. SSTR4 and SSTR5 were detectable in 85 % and 61 % of adenomas, respectively. Expression of D2R was significantly higher than that of the somatostatin receptors. The median relative expressions were as follows from highest D2R >> SSTR3 > SSTR2 > SSTR1 > SSTR5 > SSTR4. High relative expression (ratio to beta-glucuronidase mRNA > 1) of D2R was found in 60 % of tumors, high expression of SSTR1 in 7.5 %, SSTR2 in 7 %, SSTR3 in 4 % and SSTR5 in 0.5 %. The quantity of D2R correlated positively with expression of SSTR2 and SSTR3, and negatively with SSTR1 and SSTR5. Among histological adenoma types, SSTR1 was significantly higher in null-cell adenomas and SSTR3 was lower in silent corticotroph adenomas. In conclusions, in CNFAs, high expression of somatostatin receptors is much less common than that of D2R, and co-expression of both these receptors is exceptional. D2R and SSTR3 seem to be the most promising targets for pharmacological treatment.

Repetitive transcranial magnetic stimulation in the treatment of chronic orofacial pain.

Repetitive transcranial magnetic stimulation (rTMS) is non-invasive neuromodulation method. We applied rTMS for the treatment of farmacoresistant chronic orofacial pain. We compared the effect of 10 Hz and 20 Hz stimulation. The study included 23 patients for 20 Hz stimulation and 36 patients for 10 Hz stimulation with pharmacotherapy resistant chronic facial pain aged 33-65 years with pain duration of at least 6 months. Monitoring of treatment effects was performed within 15 minutes of each rTMS application (days 1-5) and finally stimulation (active vs. sham coil). If compared with data with 10 Hz rTMS study (n=36) and with 20 Hz rTMS (n=23) trials using a parallel design. Only the results obtained in a series of five rTMS treatments in the first step (active n=24, sham n=12), that 20 Hz frequency rTMS using a higher intensity (95 % of motor threshold) to be equally effective relative to VAS (Visual analogue scale) and QST (quantitative sensory testing). In conclusions, the better results with the relief of orofacial pain were obtained with 20 Hz stimulation if compared with 10 Hz stimulation. It was proved with subjective (VAS) and objective evaluation (QST). rTMS can be used in the treatment of chronic intractable pain.

Hypothalamo-pituitary dysfunction in patients with chronic subdural hematoma.

Relatively frequent pituitary hormone deficiencies are observed after traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH) and according to the published studies the neuroendocrine consequenses of traumatic brain injury are underdiagnosed. In a cohort of 59 patients (49 males, mean age 68.3 years, 36-88 years) after evacuation of subdural hematoma (SDH) were evaluated hypothalamo-pituitary functions one week after surgery, after three months and after one year. Hypogonadism was present in 26 % of patients in an acute phase, but in the majority had a transient character. Less than half of patients was GH deficient (GHD) according to the GHRH+arginine test. We did not find any serious case of hypocortisolism, hypothyroidism, diabetes insipidus centralis nor syndrome of inappropriate secretion of ADH (SIADH). Transient partial hypocortisolism was present in two cases, but resolved. We did not find relation between extension of SDH or clinical severity and development of hypopituitarism. In conclusion, in some patients with SDH growth hormone deficiency or hypogonadism was present. No serious hypocortisolism, hypothyroidism, diabetes insipidus nor SIADH was observed. The possibility of neuroendocrine dysfunction should be considered in patients with SDH, although the deficits are less frequent than in patients after TBI or SAH.

The MRI volumetry of the posterior fossa and its substructures in trigeminal neuralgia: a validated study.

PURPOSE: Our aim was to determine whether the anatomical configuration of the posterior fossa and its substructures might represent a predisposition factor for the occurrence of clinical neurovascular conflict in trigeminal neuralgia (TN). METHODS: We used MRI volumetry in 18 patients with TN and 15 controls. The volume of the pontomesencephalic cistern, Meckel's cave and the trigeminal nerve on the clinical and non-affected sides was compared. The reliability has been assessed in all measurements. RESULTS: The posterior fossa volume was not different in the clinical and control groups; there was no difference between the affected and non-affected sides when measuring the pontomesencephalic cistern and Meckel's cave volume either. The volume of the clinically affected trigeminal nerve was significantly reduced, but with a higher error of measurement. CONCLUSIONS: We did not find any association between the clinical neurovascular conflict (NVC) and the size of the posterior fossa and its substructures. MRI volumetry may show the atrophy of the affected trigeminal nerve in clinical NVC.

[Randomly discovered enlargement in the region of sella turcica]. / Náhodne zjistené expanze v selární oblasti.

Computer tomography (CT) and magnetic resonance imaging (MRI) quite often detect unexpected cases of enlargement in the hypothalamus-hypophysial region, without the above methods being indicated for clinical manifested symptomatology provoked by the tumour. This is not surprising if we consider that autopsies show the presence of hypophysial adenomas of 10-15% of population on an average. X ray, CT or MRI are indicated in the case of head traumas, lateral nasal cavity inflammations, headaches, strokes, neurological diseases and other disorders. A number of tumours of diverse etiology occur in the hypothalamus-hypophysial region, but hypophysial adenomas are by far the most frequent among all (above 90 %). Among other primary enlargements, the most frequent are craniopharyngeomas and meningeomas, while other enlargements are by fare less common. Such randomly detected tumours are mostly asymptomatic, but targeted anamnesis may show some of the symptoms quite clearly. The symptomatology can be linked with possible slight hormonal overproduction of hypophysial adenomas, a deficit of hypophysial hormones or local manifestations of expansion. Exact assessment of MRI results, of hormonal activity of the enlargement, of the relation to surrounding structures, especially the optic nerves, and the assessment of hypophysial functions are important for the therapeutic decision. Depending on the type and extension of the tumour the options considered are pharmacotherapy (the treatment of choice in the case of prolactinomas), surgery, radiotherapy (today prevailingly using the gamma knife), and if no intervention is necessary, follow up with regular MRI examinations. Tumorous growth is more often observed in "macroadenomas" than in "microadenomas" (up to 10 mm).

[Surgical approach to the sphenoid sinus in microsurgery of hypophyseal tumors]. / Operacní prístupy do sfenoidální dutiny pri mikrochirurgických operacích nádoru hypofýzy.

Currently there are three major surgical approaches into the sphenoid sinus during transsphenoidal microsurgery. The first approach is the sublabial incision with submucous resection along the nasal septum. It is particularly advantageous in patients with small nasal apertures, in pediatric patients, and for large tumors extending into the cavernous sinuses or into the clivus. The second approach, the transnasal submucous tunnel, is presently the most frequent technique used, although it provides the narrowest operation field. The third technique is the direct transnasal approach. This method is less destructive to structures in the nasal cavity and less time-consuming. In the period of 20 months the authors performed 81 transsphenoidal microsurgical operations in 44 women and 37 men. Visual field defect was the most frequent indication for surgery in 42 cases, followed by hormonal abnormality in 24 patients. The sublabial approach was used in 69 cases, the technique of transnasal submucous tunnel in 10 patients, and the direct transnasal approach in 2 cases. The authors encountered no short-term or long-term complications related to various surgical approaches to the sphenoid sinus.

Chronic subdural haematoma treatment with a rigid endoscope.

Surgical treatment is the method of choice in cases of chronic subdural haematoma--as a rule: trephination, drainage with lavage, or repeated drainage (drain reinsertion where the haematoma has been evacuated insufficiently). A poorly manageable but non-negligible group is made up of patients (about 5-12 % of all cases) where the less invasive methods of choice keep failing. The equally mini-invasive endoscopic technique appears to be one of the suitable therapeutical approaches before resorting to open-surgery revision. The adapted technique of rigid endoscope insertion permitting sufficient revision and treatment of the subdural space concerned is presented. The method is demonstrated on three case reports where routine trephination with lavage, drainage and repeated drain insertion failed. A very good improvement in clinical condition and graphic findings was achieved in two patients. In the remaining one, the neurological lesion improved ad integrum despite a tiny residual haematoma as visualized by CT. Two weeks later, a clinical relapse had developed and the patient was treated with new trephination and drain reinsertion. The technical aspects of the modification of the endoscopic technique are discussed: stressing the advantages or low-degree invasiveness, scope for keeping intact the inner membrane of the haematoma and avoiding direct invasion of the cerebral tissue. The limits of the method are discussed as well. The authors regard this method as a useful addition to the surgical armamentarium, especially in cases of chronic subdural haematomas resisting conventional approaches.

[Pleuro-dural communication]. / Pleuro-durální komunikace.

Traumatic pleuro-dural communication causing pneumocephalus needs rapid diagnostics and surgical treatment, so as to prevent the development of possible complications.

[Longitudinal fractures of the clivus]. / Longitudinální zlomenina klivu.

The authors present a rare case of the longitudinal fracture of the clival complex. Patient in good clinical condition has had fracture of frontal bone, planum sphenoideale, hypophyseal bossa and longitudinal fracture oc clivus in medial plane. Trauma was associated with cerebrospinal fluid leakage. There was performed reconstruction of anterior fossa dura vater and sealing of sphenoid sinus by muscle grafting in two step operation. The only one postoperative complication was temporary diabetes insipidus.

[Realistic possibilities of utilization of a personal computer in the office of a general practitioner]. / Reálné moznosti vyuzití osobních pocítacu v ordinaci obvodního lékare.

In May 1990 work on the programme "Computer system of the health community doctor Mic DOKI was" completed which resolves more than 70 basic tasks pertaining to the keeping of health documentation by health community doctors; it resolves automatically the entire administrative work in the health community, makes it possible to evaluate the activity of doctors and nurses it will facilitate the work of control organs of future health insurance companies and contribute to investigations of the health status of the population. Despite some problems ensuing from the contemporary economic situation of the country, the validity of contemporary health regulations and minimal training of our health personnel in the use of personal computers computerization of the health community system can be considered an asset to the reform of the health services which is under way.

[Evaluation of information sources and the effectiveness of health education in the North Bohemian Region, as indicated by knowledge of risk factors for cardiovascular diseases]. / Hodnocení informacních zdrojü a efektivita zdravotní výchovy v Severoceském kraji, vyjádrená znalostí rizikových faktorü kardiovaskulárních onemocnení.

In May 1988 in the North Bohemian region an anonymous enquiry was made among a representative group of 3,767 respondents which was focused among others on problems of health education. The respondents consider the most important source of health education in 60.37% a talk with their doctor, in 37.67% television and in 17.67% lectures. Newspaper articles, pamphlets and films are rated roughly equally (cca 5% of the respondents). Posters are negligible as a source of health education. Health education is most appreciated by the oldest age group and least by respondents aged 16-30 years. It is necessary to prefer the most appreciated forms of health education and to seek contents and forms attractive for the youngest group of patients. Part of the enquiry was focused on knowledge of risk factors of cardiovascular diseases. Smoking is considered generally most harmful, less than half know about the harmfulness of stress, few respondents know that diabetes is a risk factor (26.3%). The most frequently incorrectly mentioned factor was alcohol.

[Bribes in health care and the patients' opinions]. / Uplatky ve zdravotnictví a názory pacientu na ne.

In May 1988 in the North Bohemian region an anonymous enquiry was made in which 3,767 respondents participated. The enquiry was focused among others on the problem of bribes in the health services. In the paper the author analyzes views of respondents why they give "small gifts" to health workers and why they assume that the patients get better treatment when they bribe. The reason for making "small gifts" or bribes is in 31.3% to manifest appreciation of treatment, in 27.7% an attempt to obtain better treatment and in 7.1% fear of receiving no treatment. People above 45 years, pensioners, employees of the services and chronic patients are more convinced of the positive motive of making "small gifts". Almost 10% of the entire group are convinced of the effect of bribes as a stimulant for provision of better care, 49% deny it and the remainder do not know. The most critically minded patient groups are those working in industry and respondents under 30 years. From the entire group 1.57% admitted making "small gifts", i.e. 59 of 3,767 respondents, the motive of almost half of them (42.3%) was appreciation of the care provided by the attending staff. An unequivocal bribe to obtain better care or fear that care will be refused was involved in 45.8% of the "bribing group". The views of patients who admitted "small gifts" as regards the health services are worse than the views of all respondents.(ABSTRACT TRUNCATED AT 250 WORDS)

[Satisfaction with health services in the North Bohemia Region]. / Spokojenost se zdravotnickými sluzbami v Severoceském kraji.

In May 1988 in the North Bohemian region an anonymous survey was made in which 3,767 respondents participated, i.e. 0.42% of the population living in the region. The survey was focused on the satisfaction with and attitudes of patients to the health services. 73.64% of the respondents evaluated the provided services positively, 24.39% had an ambivalent attitude and 1.97% evaluated them negatively. Material shortcomings in the health services were criticized by 54.05% of the respondents, 37.75% criticized long waiting periods and 23.17% shortage of health personnel. The greatest advantage of our health services is that they are free of charge (49.91% respondents); availability (48.23%) and good interpersonal relations (21.56%). The satisfaction with the health services was expressed by 85.72% respondents verbally, 5.57% by criticism, 1.57% by a bribe and 1.43% by complaints. The most pretentious group are young patients working in industry. A positive attitude to the health services correlates with a positive evaluation of health workers. Thus the necessity arises to guard the ethical and professional standard of the health workers.