Minimally invasive spinal surgery using nucleoplasty and the Dekompressor tool: a comparison of two methods in a one year follow-up.

OBJECT: The Disc Dekompressor and Nucleoplasty are 2 different, minimally invasive, percutaneous methods in the therapy for chronic discogenic low back pain. The aim of this study is to compare the effectiveness of both methods concerning the outcome one year after surgery. METHODS: We included patients with MRI-proven disc protrusion suffering from low back pain and/or radiating pain in the lower extremities. The pain perception of the patients was documented using the visual analogue pain scale (VAS). Furthermore, the patients were queried about analgesic consumption, disability in daily life and ability to work. Percutaneous minimally invasive nucleotomy using the Nucleoplasty or the Disc Dekompressor was carried out under fluoroscopic and CT-guidance. We carried out a follow-up examination at 6 and 12 months after the operation. RESULTS: From April 2005 to November 2007 a total of 126 patients underwent percutaneous minimally invasive nucleotomy using Nucleoplasty (April 2005 - December 2006) or the Disk Dekompressor (February 2006 - November 2007) and were followed up after 6 and 12 months. In the Nucleoplasty group the mean age of the 27 females (39%) and 42 males (61%) was 42 years (range: 18-74). In the Disc Dekompressor group the mean age of the 22 females (39%) and 35 males (61%) was 44 years (range: 16-76). The mean duration of symptoms in the Nucleoplasty group was 30.5 months (range: 1-120), and in the Disc Dekompressor group 16.3 months (range: 1-72). Statistically significant postoperative improvement concerning the VAS score was evident in both groups. Whereas the VAS score slightly increased in the Nucleoplasty group comparing the early postoperative score and the score after 12 months, the VAS score stayed on a low level in the Disc Dekompressor group. A statistically significant reduction in analgesic consumption, disability and occupational incapacitation was observed in the Nuceloplasty group and the Disc Dekompressor group. CONCLUSIONS: Both Nucleoplasty and Disc Dekompressor are effective therapies for chronic, discogenic back pain. Regardless of the different mechanism no significant differences in the outcomes were found. Both techniques result in significant reductions in levels of disability and incapacity for work as well as decreased analgesic consumption.

Early shunting using the parallel shunt system in hemorrhagic hydrocephalus: in vitro testing of handling, technical complications and clogging rate.

In order to minimize the duration of external cerebrospinal fluid (CSF) drainage after hemorrhagic hydrocephalus we are testing a parallel shunt system that can be implanted very early after bleeding. It should be able to tolerate a high load of protein and blood in the CSF. After clearance of the CSF, the valveless arm of the shunt is closed by a percutaneous manipulation and the valve-arm is opened.

The clinical application of a new absorbable fixation clamp in craniotomy closure. A technical note after first experiences with 29 patients.

BACKGROUND: Several efforts have been made to provide safe and convenient systems for craniotomy closure. In the past, the only alternative to suture fixation was metal implants. In order to afford a bone flap fixation without leaving durable implants an absorbable fixation system has been developed by Aesculap. METHODS: In a prospective clinical evaluation we analysed intraoperative handling, position of the bone flap and stability of the connection. The planarity of the bone flaps were analysed in CT-scans on average 2 days after operation. RESULTS: Between September 2006 and October 2007 we performed craniotomy closures with the absorbable craniofix system in 29 patients. The intraoperative handling is easy when using up to 3 craniofix clamps. To ensure stability, 3 or in some cases 2, clamps are needed. Smaller bone flaps with an equal thickness of the bone tend to show a better position in the CT. We observed no complications. CONCLUSIONS: The absorbable fixation clamp is safe and convenient in small craniotomies which are properly fixed with 3 clamps. More than 3 clamps are unwieldly to use.

Long-term outcomes following decompressive craniectomy for severe head injury.

BACKGROUND: Severe head injury is one of the commonest indications for neurosurgical intervention. For the neurosurgeon, the operative last resort in cases of generalised brain oedema of traumatic origin is the decompressive craniectomy. Is it possible to use predictive factors to ascertain what degree of success, in terms of both the acute and long-term outcome, is to be expected in patients who undergo this treatment? METHODS: The clinical records of 131 patients treated with decompressive craniectomy for severe head injury were evaluated. All patients were operated on between September 1997 and September 2005 in the neurosurgical department of the Unfallkrankenhaus Berlin. A follow-up examination was carried out 49 +/- 25 months after the initial trauma. The clinical outcome was compared with several patient and radiographic factors to establish if any of these showed a relationship to the long-term outcome. FINDINGS: A significant relationship was demonstrated between quality of outcome and the Glasgow Coma Scale score on admission. Quality of outcome was similarly related to the age of the patient, the condition of the basal cisterns and the degree of midline shift in the initial cranial computed tomography. Factors which correlated with poor outcome included pupil reactivity on admission, established clotting disorders and posttraumatic hydrocephalus internus. Hyperglycaemia and initial acidosis were also associated with a poor outcome. CONCLUSIONS: The clinical outcome in patients with a severe head injury is to a great degree determined by the extent and type of the primary injury. When considering decompressive hemicraniectomy as a treatment for raised intracranial pressure following traumatic brain injury, the predictive factors detailed here should be taken into consideration.

Course of disease in patients with idiopathic normal pressure hydrocephalus (iNPH): a follow-up study 3, 4 and 5 years following shunt implantation.

BACKGROUND: In spite of recent advances in the diagnosis and treatment of iNPH, favorable outcomes following CSF diversion continue to be limited by complications, both valve dependent and valve independent, as well as by a reduction, over time, in the response to shunting. MATERIALS AND METHODS: Between September 1997 and December 2006, 148 patients underwent ventriculo-peritoneal shunt surgery in our department. All patients underwent the implantation of gravitational valves. These patients were followed-up 3, 6 and 12 months after surgery and then at annual intervals. FINDINGS: The mean age of the 94 men and 54 women in our study was 68 years. The perioperative mortality was 0.7% (one patient died from a pulmonary embolism). A further 23 patients died during the follow-up period from causes unrelated to iNPH or the surgery. This study reports on groups of patients followed-up for 2 years (n = 92), 3 years (n = 62), 4 years (n = 38) and 5 years (n = 21) postoperatively. Valve independent complications occurred postoperatively in 6% of patients (n = 10). Of these, five patients (3% of the total) had an infection and catheter displacement was recorded in a further five. Valve dependent complications occurred in 24 patients (16%), with overdrainage found in seven patients (5%) and underdrainage apparent in 17 (11%). Responder rates were 79% at 2 years, 79% at 3 years, 64% at 4 years and 60% at 5 years. The optimal valve opening pressure in programmable valves with a gravitational unit was between 30 and 70 mmHg. CONCLUSIONS: Sixty percent of patients with iNPH who underwent a ventriculo-peritoneal shunt using a gravitational valve continue to benefit from surgery 5 years postoperatively.

The role of cerebrospinal fluid flow study using phase contrast MR imaging in diagnosing idiopathic normal pressure hydrocephalus.

BACKGROUND: The purpose of this prospective study was to identify the ability of cerebrospinal fluid flow study using phase contrast MR imaging to replace the invasive methods currently used to establish the diagnosis of idiopathic normal pressure hydrocephalus (iNPH). MATERIALS AND METHODS: Between January 2003 and April 2005, 61 patients with clinical symptoms fitting the Hakim triad and a dilated ventricular system on CT underwent a intrathecal infusion test and cerebrospinal tap test. All patients also had a phase contrast MRI to determine the CSF flow rate in the aqueduct. Shunted patients were followed postoperatively up to 12 months. The pre- and postoperative symptomatic condition was evaluated using the clinical Kiefer score. The outcome was calculated by the NPH Recovery Rate. FINDINGS: Patients were classified into 41 with iNPH and 20 patients with brain atrophy. Thirty-nine iNPH patients were shunted and two patients refused surgery. The mean Kiefer score of the shunted patients was statistically significantly lower after surgery. In patients screened for clinical symptoms and ventriculomegaly on CT imaging, an aqueduct-CSF flow rate greater than 24.5 ml/min was found to be statistically specific for a diagnosis of iNPH. CONCLUSIONS: The measurement of the CSF flow rate in the aqueduct by using the phase contrast MRI technique is a highly specific pre-selective method for diagnosing iNPH.

Papilloedema in association with spinal lipoma and bilateral chronic subdural bleeding.

STUDY DESIGN: A case report describing a patient presenting with papilloedema, headache and saddle hypoesthesia caused by a lumbo-sacral intraspinal extradural lipoma in the presence of a bilateral chronic subdural haematoma (cSDH). OBJECTIVE: The aim of this report is to discuss the pathophysiology of papilloedema in spinal tumours and the effect of the cSDH on the development of papilloedema. A search of the Medline database yielded no case reports describing papilloedema arising from spinal extradural lipoma in the presence of intracranial cSDH. SETTING: Department of Neurosurgery, Unfallkrankenhaus Berlin, Berlin, Germany. CASE REPORT: We report a clinical case of cauda equina compression due to an extradural lipoma presenting with papilloedema. Cranial computer tomography (CT-scan) additionally revealed a thin, bilateral cSDH. The patient underwent surgical excision of the lipoma subsequent to an L5-S3 laminectomy. On duratomy, a membranous thrombus formation was discovered between the nerve filaments. The patient experienced clinical improvement with regression of his neurological symptoms. Histological findings confirmed the diagnosis of lipoma and intradural thrombus. CONCLUSION: Spinal tumours may cause complex cerebrospinal fluid (CSF) dynamic and resorptive changes. These changes are mechanical, physiological or combined in their effect. Patients with papilloedema or increased intracranial pressure should be carefully examined by clinical and neuro-radiological means for cranial and spinal pathologies. The treatment of the primary cause might save the patient a series of unnecessary procedures.

[Outcome after cervical anterior fusion--a clinical study of 368 patients]. / Outcomes nach ventraler Spondylodese der Halswirbelsäule--eine klinische Untersuchung von 368 Patienten.

AIM: The object of this study was to identify those factors with a direct influence on the treatment outcome of anterior cervical fusion. The clinical relevance of intervertebral cage subsidence in the course of disease is discussed. MATERIAL AND METHODS: In a prospective clinical study we followed up 368 patients with degenerative disease of the cervical spine one year after anterior fusion and cage implantation. RESULTS: We found a statistically significant association between a good outcome and young adults with monosegmental fusion of the lower cervical spine. CONCLUSIONS: Early treatment of moderate degenerative cervical disc diseases using an intervertebral cage and anterior fusion leads to a good outcome. Subsidence of the cage does not correlate with a poor outcome.

[Idiopathic normal-pressure hydrocephalus. Flow measurement of cerebrospinal fluid using phase contrast MRI and its diagnostics importance]. / Idiopathischer Normaldruckhydrozephalus. Liquorflussmessung mittels Phasenkontrast--RT und ihre diagnostische Bedeutung.

AIM: The measurement of CSF flow in the aqueduct has been a focus of interest since the development of MR imaging (MRI) techniques for this purpose in diagnosing idiopathic normal-pressure hydrocephalus (iNPH).The purpose of this prospective study was to determine the ability of this diagnostic tool to replace invasive methods in establishing the diagnosis of iNPH. PATIENTS AND METHODS: Between January 2003 and April 2005, 61 patients with the Hakim triad of clinical symptoms and dilated ventricular systems underwent the intrathecal infusion test, cerebrospinal tap test, and phase-contrast MRI to measure CSF flow rate in the aqueduct. Shunted patients were controlled 12 months postoperatively. Pre- and postoperative clinical symptoms were evaluated with the Kiefer score. Outcome was calculated according to the NPH recovery rate. RESULTS: According to these criteria the patients were classified into groups of 41 with iNPH and 20 with brain atrophy. Of the iNPH patients, 39 were shunted and two did not agree to surgery. The mean Kiefer score of the shunted patients was statistically significantly lower after surgery. The aqueductal CSF flow rate of these patients was statistically analyzed and showed that a flow rate of more than 24.5 ml/min is 95% specific to iNPH. CONCLUSIONS: Measurement of the CSF flow rate in the aqueduct using phase-contrast MRI is a highly specific preselective method for diagnosing iNPH.

Multiple intracranial hydatidosis.

BACKGROUND: Multiple intracranial hydatidosis (MIH) is a rare disease, with serious neurological manifestations, high recurrence and a mortality rate comparable sometimes to malignant disease. The causes of multiple infestations and their mechanisms are not clearly understood. Several attempts at classification are reported in the literature, but the diversity in location of these cysts in the brain and other organs, their appearance and recurrence rates remain largely unexplainable. OBJECTIVE: Multiple intracranial hydatidosis (MIH) is reported in a series of patients to evaluate their incidence, localization, complications treatment and recurrences. In this study we tried to explain the mechanism of multiple infestations, and to propose a new classification. METHODS: This was a retrospective study of thirty-four patients with MIH, treated between 1976 and 1999. The diagnosis was made mainly by CT scan and confirmed by surgery. MIH following iatrogenic rupture of a solitary cyst in the brain was excluded. Hydatid cysts were removed by the method described by Arana-Iñiguez (1973) using Dowling's technique. Histopathological examination was used to confirm the presence of scolices. The patients were followed-up for 3-14 years. RESULTS: Twenty six patients (76.4%) were under the age of 20 years with a male to female ratio of 1.0:1.83. Clinically, patients with cysts exhibited features of increased intracranial pressure and focal neurological deficit. The cysts had a diameter between 2 to 120 millimeters. Histopathological examination showed that 63.6% of the cysts were fertile. Eleven patients (46.4%) achieved a good outcome. The operative mortality rate was 10.7%. Overall mortality was 17.6%. Five patients had more than one recurrence, which appeared after 3 months to 3 years. CONCLUSION: MIH are rare; to date only 77 reported cases have been encountered. To have such a high incidence in Iraq raises the possibility of a different strain of Echinococcus granulosis. A suggestion is made regarding terminology and classification.

Population data of casework in West Virginia on six genetic marker systems.

Blood specimens and stains submitted from all geographic regions of West Virginia were analyzed for six genetic markers: International ABO, phosphoglucomutase (PGM), esterase D (ESD), erythrocyte acid phosphatase (EAP), adenylate kinase (AK), and adenosine deaminase (ADA). The four-year study indicates that markers identified were distributed in Hardy-Weinberg equilibrium and are consistent with population data previously reported.