AbstractAneurysmal subarachnoid hemorrhage (SAH) is rare in teenagers. We present the case of a 19-year-old woman with an aneurysmal SAH and four anterior circulation aneurysms. Due to the urgency of operative treatment, no initial conventional cerebral angiography was performed. The CT angiography depicted the aortic arch incompletely. The coarctation was discovered on day 5 after ictus in a cerebral angiography for vasospasm surveillance. We believe that in young SAH patients without an explainable predilection for aneurysm formation, imaging of the aortic arch during the initial CT angiography, not to miss a coarctation of the aorta, is highly recommended.
Background To evaluate whether decompression in lumbar spinal stenosis without fusion leads to sufficient improvement of back pain and leg pain and whether re-decompression alone is sufficient for recurrent lumbar spinal stenosis for patients without signs of instability. Material and Methods A successive series of 102 patients with lumbar spinal stenosis (with and without previous lumbar surgery) were treated with decompression alone during a 3-year period. Data on pre- and postoperative back pain and leg pain (numerical rating scale [NRS] scale) were retrospectively collected from questionnaires with a return rate of 65% (n = 66). The complete cohort as well as patients with first-time surgery and re-decompression were analyzed separately. Patients were dichotomized to short-term follow-up (< 100 weeks) and long-term follow-up (> 100 weeks) postsurgery. Results Overall, both back pain (NRS 4.59 postoperative versus 7.89 preoperative; p < 0.0001) and leg pain (NRS 4.09 versus 6.75; p < 0.0001) improved postoperatively. The short-term follow-up subgroup (50%, n = 33) showed a significant reduction in back pain (NRS 4.0 versus 6.88; p < 0.0001) and leg pain (NRS 2.49 versus 6.91: p < 0.0001). Similar results could be observed for the long-term follow-up subgroup (50%, n = 33) with significantly less back pain (NRS 3.94 versus 7.0; p < 0.0001) and leg pain (visual analog scale 3.14 versus 5.39; p < 0.002) postoperatively. Patients with previous decompression surgery benefit significantly regarding back pain (NRS 4.82 versus 7.65; p < 0.0024), especially in the long-term follow-up subgroup (NRS 4.75 versus 7.67; p < 0.0148). There was also a clear trend in favor of leg pain in patients with previous surgery; however, it was not significant. Conclusions Decompression of lumbar spinal stenosis without fusion led to a significant and similar reduction of back pain and leg pain in a short-term and a long-term follow-up group. Patients without previous surgery benefited significantly better, whereas patients with previous decompression benefited regarding back pain, especially for long-term follow-up with a clear trend in favor of leg pain.
Background Our objective was to investigate the effect of intraoperative dexamethasone administration on wound healing, complications, and clinical outcome in patients with posterior surgery for cervical spondylotic myelopathy (CSM). Methods We conducted a retrospective study of patients with CSM undergoing dorsal instrumentation and decompression of the cervical spine. The senior surgeon decided if administration of dexamethasone (40 mg intravenously) was indicated. Patients were divided into two groups: dexamethasone group (DG) and non-dexamethasone group (nDG). All patients were monitored for pre- and postoperative neurologic symptoms and complications. Clinical follow-up was evaluated with the Neck Disability Index (NDI) and the modified Japanese Orthopaedic Association (mJOA) score. Results A total of 49 patients were included (DG, 25; nDG, 24). DG and nDG patients showed no significant differences in pre- and postoperative findings. Five patients in the DG had wound healing complications compared with patients in the nDG (p = 0.021), and one died due to infection. Apart from that, we did not observe any significant differences between the two groups regarding complications, neurologic symptoms, and follow-up (NDI and mJOA). Conclusion Intraoperative dexamethasone administration had no influence on the postoperative outcome and follow-up. A significantly higher rate of wound infections was detected in the DG. These data support the hypothesis that intraoperative dexamethasone bolus application in CSM lacks benefit.
Abstract Background and Importance Traumatic avulsion of the ophthalmic artery is a rare cause of subarachnoid hemorrhage (SAH). In this case, a relative minor fall with isolated ocular trauma caused bulbar dislocation and rupture of the ophthalmic artery in its intracranial segment resulting in subarachnoid bleeding. Clinical Presentation In a female patient in her 70s, a direct penetrating trauma to the orbit by a door handle resulted in basal SAH with blood dispersion into both Sylvian fissures. Cerebral angiography revealed a blunt-ending stump at the origin of the ophthalmic artery. To provide protection against further bleeding, a flow diverter stent was placed in the internal carotid artery to cover the origin of the ophthalmic artery. After a longer intensive care stay complicated by pneumonia and respiratory insufficiency, the patient made a full recovery. Of all four reported cases (including ours), delayed cerebral ischemia was seen in one patient and hydrocephalus in two patients. These potential complications necessitate close observation and fitting treatment similar to aneurysmal SAH. Conclusion Due to similar physiologic aspects, this type of bleed mimics many aspects of aneurysmal SAH. In this case, we observed no hydrocephalus or the development of delayed cerebral ischemia. This represents, however, the first reported case treated by placement of a flow diverter stent to prevent rebleeding and pseudoaneurysm formation.
Abstract Objective As neurosurgery is a demanding specialty with services in larger medical centers only, consultation over larger distances plays an important role in health care. In times of digitalization, teleconsultation for medical images and cases plays an increasing role in neurosurgical services. However, no standards and demands have been established for its execution in the subfield of neurosurgery, so far. Therefore, as a first step, we performed a survey about the current state of teleconsultation in neurosurgery in Germany. Methods A standardized questionnaire consisting of 20 items was used to investigate the frequency of use and the operating conditions of teleconsultation in the field of neurosurgery. The survey was performed during the annual national German Society of Neurosurgery conference in 2017. Participation in the written survey was on voluntary and anonymous basis. Results In total, 296 individuals took part in the survey (140 specialists in neurosurgery, 77 residents). Among them, 71% were male and 121 worked at a university medical center. In total, 87.5% of all participants indicated that teleconsultation was used in their institutions (n = 113 in university medical centers and n = 76 in hospitals), and a vast majority stated to have had personal experience with it (88.6% of specialists, 85.5% of residents). The most frequent initial request for a consultation was done by phone call (80.3%). Images or data were then primarily transmitted via an electronic system (77.3%), followed by transmissions via CD or by post. The reply to a consultation was also mainly done by phone call (91.3%), followed by fax, or by e-mail. No standard protocol was followed by 78.6% of the respondents, and they stated not to know about the statutory and legal rules. However, it was stated that the protection of patient data was not endangered by using teleconsultation. The usefulness of teleconsultation and its future relevance were rated highly by the participants. The risk of misinterpretation of image data, especially without having direct access to other patient data, seemed to be a critical and unequivocal challenge. Conclusion The results of the survey demonstrate that teleconsultation for medical images and cases is a frequently used and well-accepted tool in neurosurgical health care. However, a standardized neurosurgical procedure is still lacking and the statutory rules for this field of digital medicine are generally not known in our community. Potential misinterpretation and resulting misjudgment seem to be realistic drawbacks. Thus, we see a necessity for elaboration of guidelines for teleconsultation in neurosurgery on national and European basis.
Abstract Purpose Instrumentation in spinal revision surgery is considered challenging. Altered or missing anatomical landmarks hinder the surgeons' intraoperative orientation. In recent history, the importance of navigated approaches to spinal screw placement is constantly increasing. A growing number of medical centers have introduced intraoperative CT (iCT) navigation as a new clinical standard. In this study, we compare the accuracy of dorsal iCT-navigated instrumentation in revision surgery versus primary interventions. Methods Between September 2017 and January 2019, we prospectively analyzed a consecutive series of dorsal instrumentation using iCT. Patients with previous operative interventions in the relevant spinal segments were included in the revision group and compared with a previously assessed group of primary interventions (nonrevision group). Each screw was assessed individually by an independent observer, making use of a modified Gertzbein and Robbins classification. Results In this period, 39 patients were treated in the revision group with a total amount of 269 implanted screws. We achieved an overall accuracy of 95.91% compared with 95.12% in the nonrevision group (46 patients, 287 screws). We found no significant difference in accuracy between the two groups or any anatomical region of the spine. Conclusion In summary, iCT-navigated screw placement yields a good accuracy in spinal revision surgery, without significant difference to primary interventions.
Hereinafter, we evaluate argon's neuroprotective and immunomodulatory properties after experimental subarachnoid hemorrhage (SAH) examining various localizations (hippocampal and cortical regions) with respect to neuronal damage and microglial activation 6, 24 and 72 hours after SAH. One hour after SAH (endovascular perforation rat model) or sham surgery, a mixture of gas containing 50% argon (argon group) or 50% nitrogen (control group) was applied for 1 hour. At 6 hours after SAH, argon reduced neuronal damage in the hippocampal regions in the argon group compared to the control group (P < 0.034). Hippocampal microglial activation did not differ between the treatment groups over time. The basal cortical regions did not show a different lesion pattern, but microglial activation was significantly reduced in the argon group 72 hours after SAH (P = 0.034 vs. control group). Whereas callosal microglial activation was significantly reduced at 24 hours in the argon-treated group (P = 0.018). Argon treatment ameliorated only early hippocampal neuronal damage after SAH. Inhibition of microglial activation was seen in some areas later on. Thus, argon may influence the microglial inflammatory response and neuronal survival after SAH; however, due to low sample sizes the interpretation of our results is limited. The study protocol was approved by the Government Agency for Animal Use and Protection (Protocol number: TVA 10416G1; initially approved by the "Landesamt für Natur, Umwelt und Verbraucherschutz NRW," Recklinghausen, Germany, on April 28, 2009).
Background Anterior cervical diskectomy and fusion (ACDF) or posterior foraminotomy (PF) are standard treatment options for cervical radiculopathy due to disk prolapse. Which method produces superior results has not yet been established. One reason for the dilemma, among others, is a lack of detailed outcome analysis in previous studies. We quantified outcome to compare both methods in our retrospective single-center series. Method We conducted a retrospective analysis of 107 patients with cervical radiculopathy who were operated on via ACDF or via PF. Demographic data, symptoms, neurologic status, and pathology were recorded and correlated to outcome parameters such as Odom's criteria, visual analog scale values of radicular pain, Neck Disability Index values, and subjective satisfaction, which were also compared between both treatment groups. Intraoperative data, early and late complications, and reoperations were recorded and compared between both surgical groups. Results None of the recorded preoperative data were predictive for postoperative outcome parameters. Patients in the PF group reported better overall outcome (Odom's criteria) and greater relief of radicular and neck pain. Operative time and blood loss were less in the PF group. Both groups showed comparable early complication rates, but PF patients tended to have more late reoperations. Conclusion Due to a better overall outcome as well as greater relief of radicular and neck pain in our cohort, we consider PF the first-line treatment if morphology of the pathology is suitable.
Abstract Background and Study Aims Language mapping by navigated transcranial magnetic stimulation (TMS) is commonly applied over the left language-dominant hemisphere to indicate the language-related cortex. Detailed language mapping of Broca's region including stimulation targets in the immediate vicinity to the premotor cortex may raise concern about confounding unspecific motor effects. We performed interhemispheric comparisons to delineate such possible unspecific effects from true TMS-induced language inhibition. Material and Methods Fifteen healthy German speakers named object pictures during navigated TMS over a left- and right-hemispheric target array covering the left inferior frontal junction area. Six mapping repetitions were conducted per hemisphere. Order of stimulation side was randomized between participants. Self-rating of discomfort was assessed after each stimulation; language errors and motor side effects were evaluated offline. Results Naming errors were observed significantly more frequently during left- than right-hemispheric stimulation. The same pattern was found for the most frequent error category of performance errors. Hierarchical cluster analyses of normalized ratings of error severity revealed a clear focus of TMS susceptibility for language inhibition in object naming at the dorsoposterior target sites only in the left hemisphere. We found no statistical difference in discomfort ratings between both hemispheres and also no interhemispheric difference in motor side effects, but we observed significantly stronger muscle contractions of the eyes as compared with the mouth. Conclusion Our results of (1) unspecific pre-/motor effects similarly induced in both hemispheres, and (2) a specific focus of TMS susceptibility in the language-dominant hemisphere render any substantial contribution of nonlanguage-specific effects in TMS language mapping of the inferior frontal junction area highly unlikely.
