Anomalies and malformations of lumbar spinal nerve roots.

In spinal surgery, malformations of lumbar nerve roots and their coverings may result in difficult or even faulty differential diagnoses and intraoperatively in surgical peculiarities and problems. In 5000 operations of the lumbar spine carried out within a ten-year period, 35 cases of malformation of the lumbar nerve roots were observed with 17 conjoined nerve roots emerging from the dural sac and 18 perineurial cysts in the form of cystic anomalies in the transition area of dural and arachnoid root sac into the perineurium of the spinal nerve. Due to the experience gained from these operations carried out to date, radiologic findings as to imaging as well as their interpretation, indications for surgery and intraoperative management are being discussed.

Juxta facet cysts of the lumbar spine.

The author reports on experiences in the operative treatment of juxta facet cysts of the lumbar spine. 5 cases are presented in which juxta facet cysts, causing radicular syndromes, had been successfully resected by microneurosurgery. Pathogenesis of those cysts in the course of progressive lumbar spine degeneration, especially degenerative segmental lumbar instability, is discussed.

Intradural lumbar disc herniations: report of three cases.

Intradural lumbar disc herniation is a rare pathological entity. Three new cases among a series of 5000 lumbar spine operations are added to the about 60 previous case reports in the literature. None of our patients had undergone lumbar spine surgery before. In one patient the location of the free disc fragment was medial within the dural sac; in two patients the free disc fragment had penetrated the dural sac from the axilla of the nerve root. Pathogenesis is discussed (congenital adhesions of the dura mater to the posterior longitudinal ligament at the lower lumbar spine; weakness of the dura mater ventrally and at the axilla of the nerve root). By multiplanar MRI, the free disc hernia within the dural sac may be shown preoperatively.

[Experience with intra- and perioperative high-dosage steroids in microneursurgical revision operations on lumbar discs.]. / Erfahrungen mit der intra- und perioperativen Steroidapplikation bei mikroneurochirurgischen lumbalen Rezidivbandscheibenoperationen.

UNLABELLED: A consecutive series of 100 microneurosurgical revision operations on lumbar discs has been evaluated in a prospective and randomized clinical trial analyzing the influence of dexamethasone on postoperative clinical outcome. METHODS: Of the 100 patients, 50 received dexamethasone 8 mg by local intrathecal injection during the operation and perioperative dexamethasone by a systemic route for 7 days. A reference group of 50 patients did not receive any steroids. The two groups were compared with reference to postoperative lumbar and radicular pain, regression of paresis, analgesic requirements during hospitalization and duration of stay in hospital. One year after the end of the study clinical results and ability to work in the two groups were compared. RESULTS: A significantly lower analgesic requirement was found in the dexamethasone-treated group. We found no evidence that steroids had ameliorate the regression of paresis or lumbar and radicular pain at the end of hospitalization. There was no difference in the clinical outcome 1 year after reoperation. CONCLUSIONS: After revision operations on lumbar discs, corticosteroids are a helpful adjuvant drug for relief of lumbar or radicular pain, but they do not significantly improve the final clinical outcome.

[Differential diagnosis of lumbar intervertebral disk syndrome from the neurosurgical viewpoint--personal surgical experiences with over 3,000 lumbar operations]. / Differentialdiagnosen des lumbalen Bandscheibensyndroms aus neurochirurgischer Sicht--eigene operative Erfahrungen mit über 3000 Lumbaloperationen.

Lumbar syndromes belong to the most frequent complaints in medical practice. In a series of 3110 lumbar spine operations differential diagnoses of neurosurgical relevance are represented. Diagnostic measures and operative indications are discussed.

Malformation of a cervical facet joint with inclusion of an arthrolith. Case report.

The authors present the case of a 49-year-old man with an isolated malformation of the left cervical facet joint at C5-6, with secondary spondylarthrotic hypertrophy of the joint leading to involvement of the C-6 nerve root. The etiology of this cervical joint malformation is discussed.

[Experiences with MR tomography after cervical spinal trauma]. / Erfahrungen mit der MR-Tomographie nach zervikalem Spinaltrauma.

MRI has been evaluated in a series of 26 patients, who suffered blunt cervical spine injuries at least 6 weeks previously, and had continuous clinical signs of radicular (n = 8) and medullary (n = 18) syndromes. In 6 patients MRI visualised localised posttraumatic intramedullary parenchymal changes; 5 patients had posttraumatic cord atrophies and 2 patients "traumatic" disc herniations. Besides direct traumatic lesions, pre-existing uni-, bi- or multisegmental degenerative cervical spinal stenosis must be considered because it predisposes to spinal cord injury. MRI is an important supplementary diagnostic measure after cervical spine trauma when there are clinical signs of cervical local, radicular or medullary syndromes, because intra- or extramedullary lesions can be visualised. However it must be emphasized that with present MR techniques not all "microcystic" posttraumatic spinal cord degenerations can be visualised, even if there are clear neurological signs of myelopathy or radiculopathy.

["Paralysis cruciata"--a rare brain stem lesion syndrome after cervical vertebrae trauma]. / "Paralysis cruciata"--ein seltenes Hirnstammläsionssyndrom nach HWS-Trauma.

Bell's cruciate paralysis with severe paresis or paralysis of the upper extremities and no or minimal paresis of the lower extremities represents a rare lesion of the pyramidal decussation of the lower brain-stem. MRI may show a hypointense lesion on T1-weighted imaging. Prognosis in this syndrome is dependent on the extent of involvement of surrounding brain-stem-structures, as described in three different cases.

[Lumbar and cervical "traumatic intervertebral disk displacement"]. / Zur Frage des lumbalen und zervikalen "traumatischen Bandscheibenvorfalles".

25 cases with traumatic lumbar and cervical disc herniation are described and criteria for a causal connection between trauma and prolapse are discussed: 1. The accident must be adequate, e.g. jumps from considerable height, falls, car collisions and lifting heavy weights (only in private insurance companies). 2. Typical discopathic complaints must occur soon after the accident. 3. Major degenerative disease before trauma of the vertebral column must be excluded. The medical expert has to assess in each case of possible traumatic disc herniation the cause of trauma and the resulting reduction of earning capacity.

[Malignant lymphomas with first manifestation in the spine as a rare differential diagnosis of lumbar intervertebral disk syndrome]. / Maligne Lymphome mit spinaler Erstmanifestation als seltene Differentialdiagnose zum lumbalen Bandscheibensyndrom.

Spinal epidural lymphoma need rarely be considered as a cause of lumbar nerve root compression. We report on two patients suffering from malignant epidural non-Hodgkin lymphoma, admitted with clinical and radiological signs of a lumbar herniated disc. Non-Hodgkin lymphoma can affect the spinal cord and nerve roots rarely as an isolated epidural spinal infiltration in the absence of widespread disease or - as in our two cases - as the first feature of disseminated systemic disease. Epidural non-Hodgkin lymphoma with neurological deficits should be treated by early decompressive (hemi-)laminectomy, postoperative radiotherapy and chemotherapy.

[Prevention of thromboembolism complications with low molecular weight heparin in microneurosurgical lumbar intervertebral disk operations]. / Zur Prophylaxe thrombo-embolischer Komplikationen mit niedermolekularem Heparin bei mikroneurochirurgischen lumbalen Bandscheibenoperationen.

In a prospective randomized study the effect of low-molecular-weight heparin (one injection of 1500 a PPT-Units/d Mono-Embolex NM) was compared with the effect of unfractionated heparin (5000 IU t.i.d.) in 200 patients undergoing micro-neurosurgical lumbar disc operations. Criteria of evaluation were lethal pulmonary embolisms, clinical signs of pulmonary embolisms, confirmed by radioisotopic lung scans, and major bleeding complications. The present investigation demonstrates, that a single daily subcutaneous injection of Mono-Embolex NM is an effective and well tolerated measure against thrombo-embolic complications, at least equal to the established low dose heparin prophylaxis with 5000 IU t.i.d.

[Criteria for expert assessment of the injured cervical spine from the neurosurgical viewpoint]. / Kriterien zur Begutachtung der verletzten Halswirbelsüle aus neurochirurgischer Sicht.

The assessment of cervical injuries in medical expertises can be difficult, because there are sometimes little objective clinical symptoms and radiological signs though the patients pretend to suffer from multiple complaints. A series of 40 neurosurgical expertises has been evaluated: 19 patients (47.5%) had clinical signs of cervical myelopathy, 13 patients (32.5%) had clear radicular syndromes, 7 patients (17.5%) suffered from local cervical syndromes. Clinical symptoms can be objectified by radiological methods, such as MRI, which occasionally can directly show lesions of the cervical cord or the brain stem. Sometimes even in patients with severe neurological deficits there are little radiological alterations. Local pain syndromes were assessed at a reduction in earning capacity of about 20%, radicular syndromes at 20 to 30%, minor grades of myelopathy at 30 to 40% respectively disability, and severe grades of myelopathy at up to 100% resp. incapacity of gainful employment. In our opinion adequate assessment of cervical cord injuries should predominantly base on clinical neurological findings, secondarily on radiological findings.

[Clinical aspects and diagnosis of lumbosacral perineural cysts]. / Zur Klinik und Diagnostik lumbo-sakraler Perineuralzysten.

Perineurial cysts are sometimes space-occupying cystic dilatations of the lumbo-sacral nerve roots at or distal to the junction of the posterior root and the dorsal ganglion. The wall is composed of perineurium and neural tissue. We report on 2 cases of upper sacral perineurial cysts with their computed tomography and myelography findings. Indication for operation is discussed: perineurial cysts should only be operated on if their clinical symptoms are clearly attributable to them and other causes like degeneration of the lumbar spine can be excluded.

[Ligamentous connections of the spinal processes]. / Bandverbindungen der Dornfortsätze der Wirbelsäule.

In the cervical region the fibres of the interspinous and nuchal ligaments pass in an anterocranial direction: they act against diminishing of the cervical lordosis. In the thoracic region, longitudinal bundles of fibres connect the tops of the spinous processes; they act against an augmentation of the thoracal kyphosis. Between thoracal kyphosis and lumbal lordosis there is no exact course of the fibres of the interspinous ligts. ("thorakolumbaler Ubergangsbereich"). In the lumbar spine the fibres of the interspinous ligts., being very strong, pass in a posterocranial direction. They have the function of limitation the range of flexion ventrally and of limiting backwards-shifting of the cranial vertebra in dorsal-flexion. In the lumbosacral segment additional fibres, arising from the top of the 5th lumbar spinous process, pass in a posterocaudal direction and interlace with the thoracolumbar fascia, whose fibres form--below the 4th lumbar vertebra--a scissor-latticed structure. The supraspinous ligt. lies superficially to the thoracolumbar fascia. Its fibres pass several spinous processes. It ends caudally at the 4th lumbar spinous process.

[Stage-III cerebrovascular insufficiency in stenoses and occlusions of the extracranial A. carotis. An indication for surgery?]. / Zerebrovaskuläre Insuffizienz Stadium III bei Stenosen und Verschlüssen der extrakraniellen A. carotis.

Reconstructive surgery was performed on 93 patients with stage III cerebrovascular insufficiency, extracranial stenoses and (or) occlusions of the cerebral blood flow. Compared with the spontaneous course in acute stroke, results of surgery point towards recommending an aggressive procedure provided certain criteria are observed (time limit, absence of haemorrhagia), particularly in view of the potential mortality of the condition. Late prognosis, assessed on the basis of 40 patients subjected to neurological follow-up 4 1/2 years after the operation, can be considered favourable.

[Morphology and function of the interspinal ligaments and the supraspinal ligament of the lumbar portion of the spine]. / Morphologie und Funktion der Ligamenta interspinalia und des Ligamentum supraspinale der Lendenwirbelsäule.

The collagenous bundles of fibres in the lumbar interspinous spaces belong to different anatomical structures: the true interspinous ligaments, connecting two neighboured spinous processes in a postero-cranial direction, and fibres, lying in the dorso-caudal part, belonging to the thoracolumbar fascia (aponeurosis of the sacrospinal muscle). In the lumbo-sacral segment there are additional fibres arising from the dorsal part of the 5th lumbar spinous process and descending in a postero-caudal direction, interlacing with the thoracolumbar fascia. Superficial to the thoracolumbar fascia the fibres of the supraspinous ligament pass several spinous processes and form a longitudinal cord. Caudally the supraspinous ligament ends normally at the 4th lumbar spinous process. Below the caudal end of the supraspinous ligament the fibres of the thoracolumbar fascia cross to the opposite side and form a scissor-latticed structure. The interspinous ligaments limit the ventral-flexion of the lumbar spine; they can be extended in extreme retro-flexion, too. Downwards of L4 the fibre-texture of the thoracolumbar fascia permits a greater extent of ventral-flexion. In these segments the erector spinae muscle has to ensure the stability of the spine motion segments instead of a longitudinal ligamentous connection.