A. Nabhan

The Prodisc-c Prothesis: Clinical and Radiological Experience 1 Year After Surgery

Study Design. This is a prospective randomized and controlled study, approved by the local ethical committee of Saarland (Germany). Objective. The aim of the current study was to analyze segmental motion following artificial disc replacement using disc prosthesis over 1 year. A second aim was to compare both segmental motion as well as clinical result to the current gold standard (anterior cervical discectomy and fusion [ACDF]). Summary of Background Data. ACDF may be considered to be the gold standard for treatment of symptomatic degenerative disc disease within the cervical spine. However, fusion may result in progressive degeneration of the adjacent segments. Therefore, disc arthroplasty has been introduced. Among these, artifical disc replacement seems to be promising. However, segmental motion should be preserved. This, again, is very difficult to judge and has not yet been proven. Methods. A total of 49 patients with cervical disc herniation were enrolled and assigned to either study group (receiving a disc prosthesis) or control group (receiving ACDF, using a cage with bone graft and an anterior plate). Roentgen stereometric analysis (RSA) was used to quantify intervertebral motion immediately as well as 3, 6, 12, 24, and 52 weeks after surgery. Also, clinical results were judged using visual analog scale and neuro-examination at even RSA follow-up. Results. Cervical spine segmental motion decreased over time in the presence of disc prosthesis or fusion device. However, the loss segmental motion is significantly higher in the fusion group, when looked at 3, 6, 12, 24, and 52 weeks after surgery. We observed significant pain reduction in neck and arm after surgery, without significant difference between both groups. Conclusion. Cervical spine disc prosthesis remains cervical spine segmental motion within the first 1 year after surgery. The clinical results are the same when compared with the early results following ACDF.

Microsurgical excision of symptomatic sacral perineurial cysts: a study of 15 cases

BACKGROUND The widespread use of magnetic resonance imaging (MRI), now the first line investigation for back and leg pain, reveals cystic sacral lesions more often than myelography did in the past. There is agreement that symptomatic perineurial sacral cysts should be treated surgically. However, it is still debated whether the preference should be given to the curative option, consisting of excision of the cyst with duraplasty, or to drainage of the cyst to relieve symptoms. In this retrospective study the efficacy of microsurgical cyst resection with duraplasty is evaluated. METHODS In 15 patients presenting with pain and neurologic deficits, myelography and/or MRI detected sacral cysts. The clinical features suggested that the space-occupying lesions caused the disturbances. Microsurgical excision of the cyst along with duraplasty or plication of the cyst wall was performed in all the cases. Postoperative care included bed rest and CSF drainage for several days. RESULTS In 13 out of 15 patients the preoperative radicular pain disappeared after surgery. The 2 patients with motor deficits and the 6 patients with bladder dysfunction recovered completely. In all except 1 of the 10 patients complaining of sensory disturbances a significant improvement was achieved. No complications were observed. CONCLUSION Microsurgical excision of the cyst combined with duraplasty or plication of the cyst wall is an effective and safe treatment of symptomatic sacral cysts and, in the view of the authors, the method of choice.

Skull base tumors

Modern imaging techniques have great importance in the diagnosis and therapy of skull-base pathologies. Many of these lesions, especially in relation to their specific location, can be evaluated using CT and MR imaging. Tumors commonly found in the anterior skull base include carcinoma, rhabdomyosarcoma, esthesioneuroblastoma and meningioma. In the central cranial fossa, nasopharyngeal carcinoma, metastases, meningioma, pituitary adenoma and neurinoma have to be considered. The most common neoplasms of the posterior skull base, including the CP angle, are neurinoma, meningioma, nasopharyngeal carcinoma, chordoma and paraganglioma. One major task of imaging is the evaluation of the exact tumor extent as well as its relationship to the neighboring neurovascular structures. The purpose of this review is to recapitulate the most important anatomical landmarks of the skull base. The typical imaging findings of the most common tumors involving the skull base are also presented.

Comparison of bioresorbable and titanium plates in cervical spinal fusion: early radiologic and clinical results.

Study Design This is a prospective, randomized, and controlled study, approved by the local ethical committee of Saarland (Germany), no. 209/06. Objective The aim of this study was to compare clinical results, segmental motility, magnetic resonance imaging (MRI) compatibility, and change of the bone density of a cervical spine segment that was treated with either bioresorbable or titanium plates in single level. Summary and Background Data Anterior cervical discectomy and fusion including plate fixation is an accepted technique for treatment of symptomatic degenerative disc disease. Titanium plates have been used but cause imaging artifacts. Radiolucent bioresorbable plates and screws were developed to reduce the imaging artifacts associated with titanium. Methods Forty patients with single level cervical radiculopathy were randomized to anterior discectomy and fusion with bioresorbable plate (19 patients, study group) or titanium plate (18 patients, control group). Follow-up used a visual analog scale (VAS) with regard to brachial pain and Neck Disability Index (NDI) for neck pain. Radiostereometry was performed immediately postoperative and after 6 weeks, 3, and 6 months. MRI of the cervical spine was obtained immediately postoperatively at 3 and 6 months to assess hematoma, infection, and swelling. Computed tomography of the operated cervical spine segment was performed to assess bone density, expressed in Hounsfield units. Results Three-dimensional analysis of segmental motion (medio-lateral, cranio-caudal and anterior-posterior) did not reveal any statistical difference between both groups at any time postoperatively (P>0.05). Fusion rate and speed evaluated on Radiostereometric analysis and computed tomography of cervical spine segment were similar in both groups. MRI of cervical spine did not show any pathology, especially hematoma and infection. The VAS and NDI did not differ between both groups after 6 months (P>0.05). Conclusions Anterior plate fixation by using a bioresorbable plate has the same fusion progress and stability as titanium. During the study, no complications like soft tissue swelling and infection occurred.

Subcutaneous local anesthesia versus intravenous regional anesthesia for endoscopic carpal tunnel release: a randomized controlled trial.

OBJECT This study compares the effectiveness of subcutaneous infiltration of a local anesthetic agent (LA) versus intravenous regional anesthesia (IVRA) during endoscopic carpal tunnel release. METHODS Forty-four patients suffering from severe symptoms restricting normal daily activities-such as persistent loss of feeling in the fingers or hand, or no strength in the thumb in spite of prolonged nonsurgical treatment-and with electromyographically proven carpal tunnel syndrome were enrolled in this study. All underwent endoscopic carpal tunnel release. Twenty-two patients had an endoscopic release of the median nerve under LA (LA Group). The other 22 patients underwent the surgery after intravenous induction of regional anesthesia (IVRA Group). The operating room in-out time and tourniquet time were evaluated in both groups. The patients were also asked to evaluate the pain associated with the tourniquet during surgery using a visual analog scale. The Michigan Hand Outcomes Questionnaire was used to assess the functional outcome preoperatively and at both 2 weeks and 6 months postoperatively. RESULTS One patient in the LA Group needed an additional application of prilocaine, whereas 3 patients in the IVRA Group needed additional LA and 1 of these required propofol. The tourniquet time and operating room time were significantly lower in the LA Group (p = 0.01 for both). There were no complications related to the endoscopic surgery. The Michigan Hand Outcomes Questionnaire did not show significant differences between the groups at either postoperative follow-up examination. CONCLUSIONS Endoscopic carpal tunnel release with subcutaneous infiltration of LA was well tolerated and effective. Injection-associated problems such as increased thickness of the synovial layer or impaired endoscopic view did not occur.

Intraoperative CT in Spine Surgery

BACKGROUND In spinal instrumentation the misplacement of screws, cages and rods may cause neurovascular complications. Therefore a large variety of methods have been used in recent years to reduce such complications especially by navigation techniques and intraoperative three-dimensional fluoroscopy. The aim of this study is to answer the question: will intraoperative CT improve the efficiency of the treatment as well as the safety for the patient at the spinal instrumentation? Specific questions were: are the implants placed correctly and has decompression been performed sufficiently? METHODS This is a prospective study in 100 patients mostly with degenerative diseases, tumours and trauma. 80 patients were treated by spinal instrumentation. A helical CT (Somatom Emotion 2003) was used, which is firmly bound to the OR table by a track system. RESULTS 569 implants were used: 159 vertebra body screws and plates, 88 cages, 154 pedicle screws, 73 facet joint screws and 95 rods. There was malpositioning in seven patients (8.75%). 18 of 154 pedicle screws were misplaced, 2 of 88 cages, and 4 of 73 facet joint screws, for a total of 24 (7.6%). CONCLUSIONS Intraoperative CT is a useful tool to check the correct position of the implants used, the extent of decompression and the realignment as early as possible. It therefore reduces second operations. A postoperative CT is no longer necessary.

Spinale Tumoren@@@Spinal tumours

ZusammenfassungSpinale Tumoren können intramedullär, innerhalb der Meningen (intradural), zwischen Meningen und Knochen (extradural) auftreten oder von anderen Lokalisationen sekundär zu einer Beteiligung der Wirbelsäule führen. Das Wirbelkörperhämangiom ist der häufigste gutartige Tumor der Wirbelsäule. Zu den häufigsten malignen spinalen Tumoren gehören Metastasen, das Lymphom und das multiple Myelom. Primäre Knochentumoren der Wirbelsäule sind im Vergleich dazu eher selten und zeigen auch oft charakteristische Bildbefunde. Für die Differenzialdiagnostik spielen das Patientenalter, die Lokalisation des Tumors und die magnetresonanz- und computertomographischen Befunde eine wichtige Rolle.AbstractSpinal tumors can be intramedullary, intradural (within the meninges), or extradural (between the meninges and the bones), or they may extend secondary to the spine from other locations. Vertebral hemangioma represents the most common benign tumor of the spine. Metastases, lymphoma, and multiple myeloma are the most frequent malignant spinal tumors. Primary osseous tumors of the spine, in contrast, are rare conditions but may demonstrate typical imaging findings. For the differential diagnosis, the patient’s age, the topographic localization of the mass, and morphologic features of the lesion as depicted by computed tomography and magnetic resonance imaging play important roles.

Imaging of extradural spinal lesions

ZusammenfassungDas Spektrum der spinalen extraduralen Tumoren ist sehr groß. Neben echten Neoplasien können auch degenerative Veränderungen und Anlagestörungen sowie entzündliche Veränderungen Ursachen einer extraduralen Raumforderung sein. Aufgrund der knöchernen Begrenzung des Spinalkanals können neben Malignomen auch benigne Tumoren und degenerative spinale Veränderungen zu progredienten neurologischen Ausfallsymptomen (einschließlich Querschnittsymptomatik) führen. Die überwiegende Mehrzahl der extraduralen Raumforderungen der Wirbelsäule ist benigne (Hämangiom des Wirbelkörpers, degenerative Erkrankungen). Bei jungen Patienten sind Anlagestörungen und primäre Wirbelsäulentumoren zu berücksichtigen, wogegen beim Erwachsenen an sekundäre Malignome, wie Metastasen und Lymphome sowie eine metabolische Erkrankung, wie die osteoporotische Wirbelkörpersinterungsfraktur oder der Morbus Paget, differenzialdiagnostisch gedacht werden sollte. Schnittbilddiagnostische Verfahren, wie die Computertomographie und die Magnetresonanztomographie, der Wirbelsäule ermöglichen in vielen Fällen eine artdiagnostische Zuordnung von Wirbelsäulenläsionen und sind ein wichtiges Instrument für das Tumorstaging und die präoperative Planung.AbstractThere is a wide variety of spinal extradural tumors. In addition to real neoplasms, degenerative diseases, congenital abnormalities and inflammatory disorders can be causes of extradural masses. Due to the bony boundary of the spinal canal, both benign as well as malignant masses can cause progressive neurological deficits including paraplegia. Most of the spinal tumors are benign (hemangioma of the vertebral body, degenerative diseases). In younger patients congenital abnormalities and primary tumors of the spine have to be considered, whereas in adults the list of differential diagnoses should include secondary malignancies such as metastases and lymphomas as well as metabolic disorders such as osteoporotic vertebral compression fracture and Paget’s disease. Cross-sectional imaging techniques such as magnetic resonance imaging (MRI) and computed tomography (CT) of the spine often help to make a specific diagnosis of extradural spinal lesions and represent important tools for tumor staging and preoperative evaluation.

Endoscopic Carpal Tunnel Release using a modified application technique of local anesthesia: safety and effectiveness

Background Local anesthesia is widely used for open carpal tunnel release. However, injection of local anesthesia as described by Altissimi and Mancini (1988) can interfere with endoscopic carpal tunnel release, by increasing the bulk of synovial layers and consequently result in worsening of the view. Purpose The purpose of this study was to evaluate the safety, efficacy using modified technique for application of local anesthesia. Methods 33 patients suffering from gradual increasing symptoms of carpal tunnel syndrome. The patients were also asked to evaluate the pain associated with injection as well as tourniquet during surgery using Visual Analogue Scale (VAS) (ranging from 0 = no pain to 10 = maximum pain). Results One patient required additionally local anesthesia because of mild pain in the hand. The tourniquet was inflated for 13.00 (2.8 min). The pain score related to injection was 2.5 (0.8) and to tourniquet was 3.6 (0.9). Inflation of the tourniquet was well tolerated by all patients. Postoperative neurological sensory and motor deficits related to surgery and local blocks were not occurred. Conclusion Endoscopic release of the carpal tunnel syndrome in local anesthesia is effective, well tolerated and safe. This kind of application of local anesthesia did not reduce visibility.

Bildgebung extraduraler Raumforderungen

ZusammenfassungDas Spektrum der spinalen extraduralen Tumoren ist sehr groß. Neben echten Neoplasien können auch degenerative Veränderungen und Anlagestörungen sowie entzündliche Veränderungen Ursachen einer extraduralen Raumforderung sein. Aufgrund der knöchernen Begrenzung des Spinalkanals können neben Malignomen auch benigne Tumoren und degenerative spinale Veränderungen zu progredienten neurologischen Ausfallsymptomen (einschließlich Querschnittsymptomatik) führen. Die überwiegende Mehrzahl der extraduralen Raumforderungen der Wirbelsäule ist benigne (Hämangiom des Wirbelkörpers, degenerative Erkrankungen). Bei jungen Patienten sind Anlagestörungen und primäre Wirbelsäulentumoren zu berücksichtigen, wogegen beim Erwachsenen an sekundäre Malignome, wie Metastasen und Lymphome sowie eine metabolische Erkrankung, wie die osteoporotische Wirbelkörpersinterungsfraktur oder der Morbus Paget, differenzialdiagnostisch gedacht werden sollte. Schnittbilddiagnostische Verfahren, wie die Computertomographie und die Magnetresonanztomographie, der Wirbelsäule ermöglichen in vielen Fällen eine artdiagnostische Zuordnung von Wirbelsäulenläsionen und sind ein wichtiges Instrument für das Tumorstaging und die präoperative Planung.AbstractThere is a wide variety of spinal extradural tumors. In addition to real neoplasms, degenerative diseases, congenital abnormalities and inflammatory disorders can be causes of extradural masses. Due to the bony boundary of the spinal canal, both benign as well as malignant masses can cause progressive neurological deficits including paraplegia. Most of the spinal tumors are benign (hemangioma of the vertebral body, degenerative diseases). In younger patients congenital abnormalities and primary tumors of the spine have to be considered, whereas in adults the list of differential diagnoses should include secondary malignancies such as metastases and lymphomas as well as metabolic disorders such as osteoporotic vertebral compression fracture and Paget’s disease. Cross-sectional imaging techniques such as magnetic resonance imaging (MRI) and computed tomography (CT) of the spine often help to make a specific diagnosis of extradural spinal lesions and represent important tools for tumor staging and preoperative evaluation.