[The results of percutaneous diskectomy. The course of pain, work capacity and therapy failure]. / Ergebnisse der perkutanen Diskektomie. Schmerzverlauf, Arbeitsfähigkeit und Therapieversagen.

In a prospective study extending from November 1989 to December 1992 percutaneous discectomy was carried out in 50 patients (26 men, 24 women, mean age 41 [19-73] years). The aim of the study was to ascertain the efficacy of this new mode of treatment, and its indications. The patients selected for the procedure had chronic, therapy-resistant lumboradicular pain syndrome of at least six weeks' duration; imaging procedure had to show a "bulging disc" and neurological deficits had to be no more than minor. During the subsequent follow up period of 22 +/- 9.6 months 35 of the 50 patients did not require any further surgery; 24 of them (69%) resumed full work while seven (20%) regained partial (50%) working capacity. However, the operation proved ineffective in four of these 35 patients (11%). Fourteen of the 50 patients (28%) had persistent pain and required revision by open classical discectomy; seven of them resumed full work and one regained 50% working capacity. The most frequent findings at this revision were stenosis of the subarticular recess in combination with persistent forward bulging of the longitudinal ligament and anulus fibrosus (n = 7), calcification of the posterior longitudinal ligament (n = 1) and an intervertebral disc sequestrum which gave a false negative results on discography (n = 2). In another case there was a genuine recurrence 35 months after a successful percutaneous procedure; this was treated successfully by open operation. When performed at the level L5/S1, the procedure gave unsatisfactory results in five out of six cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intraventricular hemorrhage]. / Intraventrikuläre Blutungen.

In the University Cantonal Hospital in Basel, 34 intraventricular hemorrhages were diagnosed by computer tomography from 1981 to 1990. The most frequent cause of bleeding into the ventricular system (35.3%) was rupture of an aneurysm, followed by hypertensive hemorrhages (23.5%). The cause of bleeding into the ventricular system could not be found in 20.6% of the cases investigated. The hemorrhage was present in all ventricles in 13 cases. A ruptured aneurysm was responsible for this in five patients. The hemorrhage was found in two and three ventricles in 11 cases. Only one ventricle was filled with blood in 10 cases; this was due to hypertensive hemorrhage in four patients. Besides open and enclosed ventricular drainage, aneurysm clipping was carried out in six cases, osteoplastic craniotomy in 12 cases and bore hole trepanation in four cases, depending on the underlying disease responsible for bleeding into the ventricular system. We were able to observe restitution of complete functional integrity at the follow-up examination one year later in eight cases (23.53% of all patients). Neurological deficits were shown at follow-up in 10 cases (= 29.41%). In our patients, the mortality was 47.1% (= 16 patients).

[Decompressive craniotomy and its effect on recovery and rehabilitation of the patient]. / Dekompressive Kraniotomie und deren Einfluss auf Erholung und Rehabilitation des Patienten.

The rehabilitation of patients who have to be operated on because of severe craniocerebral trauma and in whom the roof of the cranium must be removed because of severe post-traumatic cerebral oedema, is extremely difficult. The slow rehabilitation and recovery of these patients, who also show psychological changes in most cases, must be attributed to the pathological intracranial conditions which have arisen in consequence of large defects in cranial bones. A causal correlation between severe pathological intracranial conditions, which have arisen not only from trauma but also from bone flap decompressions, and protracted postoperative recovery and difficult rehabilitation has only recently been established. Our experience has shown that rapid rehabilitation of the injured person can only be expected after skullcap reconstruction and normalization of intracranial conditions.

[Severe herpes simplex encephalitis: course 15 years following decompressive craniotomy]. / Schwere Herpes-simplex-Enzephalitis: Verlauf 15 Jahre nach dekompressiver Kraniotomie.

Decompressive craniotomy with brain biopsy was carried out in two patients with herpes simplex virus encephalitis (HSE). In both cases the indication for surgery was based on the clinical picture of coma with rapidly progressive hemiparesis and on the computer tomographic finding of a large space-occupying lesion of in the temporal lobe accompanied by brain stem compression not controllable by medication. Both patients were treated with a standard dosage of vidarabine (Ara-A 15 mg/kg/24 h) and corticosteroids after the operation. The improvement attained by surgery was very impressive in both cases. The massive neurological deficits (which also included subtotal aphasia in one case) regressed to a minimum in the following weeks. Both patients were followed up at yearly intervals for 15 years. They are now 36 and 76 years of age, both in a very satisfactory condition. Our observations show that decompressive craniotomy with duraplasty may be the crucial therapeutic measure in HSE with brainstem compression not controllable by medication.

[Chemonucleolysis with chymopapain in lumbar disk hernia. Randomized comparative study with operated patients]. / Chemonukleolyse mit Chymopapain bei der lumbalen Diskushernie. Randomisierte Vergleichsstudie mit operierten Patienten.

We carried out a randomized comparison study with 69 patients, one group of whom had been operated on (41) and the other group treated by chemonucleolysis with chymopapain (25) in order to arrive at an objective picture of the latter recently much criticised method. 88% of the patients who were treated with chymopapain showed lasting success, and almost 90% of the operated patients are also in a good condition. In our opinion, complications can be avoided and the patient can be spared a surgical operation by the correct choice of patients and proper performance of the method in standby anaesthesia. This justifies the performance of chemonucleolysis with chymopapain.

[Decompressive craniotomy in severe craniocerebral trauma following unsuccessful treatment with barbiturates]. / Dekompressive Kraniotomie bei schwerem Schädelhirntrauma nach erfolgloser Behandlung mit Barbituraten.

During the period from September 1983 to October 1984 the intracranial pressure of 51 patients who had suffered cranio-cerebral trauma was continuously recorded. In 21 patients (41%) the intracranial pressure remained within normal limits (10-25 mm Hg) and apart from hyperventilation and corticosteroids no other treatment was required. All these patients recovered satisfactorily. In 28 patients the raised intracranial pressure could not be reduced by means of hyperventilation, corticosteroids and osmotherapy so that barbiturates had to be administered. Seven patients did not respond to this additional treatment and a decompression craniotomy was necessary. The progress, treatment, complications and prognosis of such patients are discussed.

[Development, symptomatology and treatment of "animal" and "plant" parasites of the central nervous system]. / Entwicklung, Symptomatologie und Behandlung der "tierischen" und "pflanzlichen" Parasiten des Zentralnervensystems.

Eight cases of today rather rare infections of the brain and spinal cord with animal and plant parasites are described. Echinococcus was identified in one patient, cysticercus cellulosis in 4 and in 3 patients various fungi (actinomycosis Meyerii, aspergillus fumigatus, nokardiose asteroides) were found. Prior to the admission to the hospital none of these patients were correctly diagnosed. Animal parasites mimicked the symptomatology of a brain tumour or of a space occupying process. If localised intraspinally they produced signs similar to prolapsed lumbar disc. Plant parasites caused formation of particular suppurative granulation tissues in the form of abscesses which were often disseminated. By contrast, animal parasites produced only mechanical damage of the brain tissue. In addition to surgical intervention aiming at complete removal of parasite cysts or abscesses, drug therapy with the broadspectrum antibiotics or Praziquantel, an isochinoline derivate, is appropriate. Although due to the better diagnostic procedures and specific drug treatment the mortality rate in the countries with widespread parasite infections (Southern Europe and South America) has dropped from 50-80% to 5-6%, the experience shows that only about half of the patients survive the operation when a longer time-span is considered.

[Intracranial pressure measurement in large skull defects]. / Intrakranielle Druckmessung bei grossen Schädelkalottendefekten.

We measured the intracranial pressure continuously for a period of four days before and after cranioplasty in 12 patients with skull defects larger than 100 cm2. The results were obtained by epidural monitoring. The device used was the "Hellige" pressure measuring device (modified according to Gobiet). We found an increased cranial pressure in more than half of the patients (7). In addition the same patients showed the most marked neurologic and psychic changes. A significant return to normal of the intracranial pressure was noticed in all these patients after the closure of the skull defect. Progressive improvement in the clinical symptoms was also seen. The pathogenesis of this phenomenon has not been completely explained. Several authors consider that an important factor is the difference between the intracranial and the atmospheric pressure, However, we suggest that another important factor is the cicatricial changes ("scar plate") occurring between the cortex, dura and the skin, which exerts pressure on the skull contents. Previously, the neurological symptoms which appeared after a period of time in patients with large skull defects were attributed to other causes. It is only during the past decades--thanks to progress in neuroradiologic diagnostics--that a pathoanatomical correlate been found for these changes.

Topographic studies with 32P tumor marker during operations of brain tumors.

A method for the intraoperative detection of brain tumor propagation is described. Based on the well-known radiophosphorus test, a very sensitive semiconductor probe was tested in 16 brain tumor operations. With this miniaturized sensor, the beta-emission of 32P could be measured with a high topographical resolution. Especially in high-grade gliomas, in meningiomas and in metastases a good discrimination of normal and tumor-infiltrated tissue was possible. The perspectives of a technical improvement of this method and the application of more specific tumor markers are discussed.

[Intracranial pressure measurement--indications and results]. / Intrakranielle Druckmessung--Indikation und Ergebnisse.

Intracranial pressure was measured in 82 patients in the Neurosurgical Clinic, Basle, from 1978-1982. The methods used werette Gobiet Screw (62 patients), the Gealtec Probe (17 patients) and intraventricular drainage. Intracranial pressure monitoring was carried out in 54 patients with severe craniocerebral injury in 12 patients with large cranial bone defects and a subsequent cranioplasty, in 12 patients to diagnose hydrocephalus and in 4 patients for other reasons. Indications for intracranial monitoring results and therapy are discussed.

[Primary brain tumors in psychiatry]. / Primäre Hirntumoren in der Psychiatrie.

At the University Psychiatric Clinic in Basle, 14 primary brain tumours were diagnosed in a patient population of 12,530 in the course of 10 years. The rate of primary brain tumours in hospitalized psychiatric patients is thus one in 1,000. Primary brain tumours occurred 20 times more frequently in psychiatric patients than in a normal population, in whom the rate is one in 20,000. The classic brain tumour triad frequently occurs late and is found in less than 50% of patients. In 50 to 60 percent, brain tumour is associated with mental changes, mainly confusional states and psychoorganic syndrome. There is no typical pathopsychology of brain tumours, and that is why the possibility must always be ruled out. On the basis of these remarks, concrete recommendations are made for daily practice.

[Results of the first hundred cerebral bypass operations in Basel]. / Ergebnisse der ersten hundert zerebralen Bypass-Operationen in Basel.

This is a report on clinical findings after 100 extra-intracranial bypass procedures for cerebral ischemia. The patients presented with transient ischemic attacks, prolonged ischemic neurological deficits, completed strokes, low perfusion syndromes and ischemic ocular diseases. The microvascular anastomosis is performed between a branch of the external carotid artery and a cortical branch of the middle cerebral artery. In 10 patients we performed a bilateral bypass. We had no mortality. The morbidity was 5%, the patency rate 96%. The effect of the microvascular procedure can be determined by comparing the postoperative follow-up (averaging 22 months) and the natural course of cerebrovascular disease. Clinical benefit is gained in the elimination of transient ischemic attacks. Patients considered candidates for diagnostic studies are those presenting with completed strokes. Finally in patients with large aneurysms extra-intracranial bypass procedures may prove to be of value, when carried out in a combined approach.

[Cranioplasty after extensive decompressive craniotomy with displacement of the cerebral hemisphere. CA analysis (author's transl)]. / Schädeldachplastik nach grossen dekompressiven Kraniotomien mit Massenverschiebung. CT Analyse.

Cosmetic aspects and protection of the brain from mechanical injuries are the most common indications for the repair of traumatic and operative cranial defects. We suggest two additional indications: Cranioplasty is not only important in the treatment of space-occupying fluid cysts, but also in preventing or overcoming hemisphere collapse with its resultant displacement of the midline structures. This complication was almost exclusively found in patients subjected to extensive lateral craniotomies and also led to psycho-organic syndromes with disturbances of mood and drive. In few cases a crippling hemiparesis and epileptiform fits were also present. The recovery of the patients was almost complete after the repair of the cranial defect. Clinical improvement was due to restitution of physiological intracranial pressure state and re-expansion of the cerebral hemispheres as could be shown by computer tomography. The operative procedure of auto-, homo- and heteroplastic cranioplasty is described, with particular emphasis on the new technique with acrylic plastic, developed by the authors.

[Decompressive craniotomy in herpes simplex encephalitis]. / Dekompressive Kraniotomie bei der Herpes-simplex-Enzephalitis.

Two patients with herpes simplex encephalitis (HSE) underwent decompressive craniotomy with brain biopsy. The indication for the procedure was in both cases computertomographic finding of a large, space-occupying process situated in the temple lobe with clinical picture involving febrile state, progressive hemiparesis, and subconsciousness. The patients were treated with standard doses of Ara A and methylprednisolone immediately after operation. In both cases, the improvement was very impressive. The massive neurological deficits -- in one case even including subtotal aphasia -- disappeared almost completely in the weeks following operation. 6 months later both patients underwent cranioplasty. These observations show that decompressive craniotomy with dilatation of the dura represents a decisive therapeutic approach in the case of HSE when the pressure of the brain cannot be brought under control by medical treatment. Computertomography proved to be of particular diagnostic value and assists in taking decisions for meaningful surgical treatment.

[Brain abscess after odontogenic infection]. / Hirnabszess nach dentogenem Infekt.

Dentogenous infections are among the most frequent in the maxillo-facial area. Case report of a dentogenous-pyogenous-actinomycotic mixed infection, with the complication of a secondary brain abcess is given. Consecutively, the patient became an invalid. Origin and pathogenesis of the disease are described. Also, liberal incision and drainage as a preventive measure are recommended.