F. Loew

Traumatic, spontaneous and postoperative CSF rhinorrhea.

CSF fistulas are a major complication of head injury but also occur spontaneously or symptomatically in connection with tumours of the skull base, empty sella syndrome, ethmoidal encephalomyelocele, intracranial hypertension or postoperatively in connection with operations on skull base tumours or ENT operations. Their main risk is the possibility of meningitis. The main clinical symptom is CSF leakage from the nose, but meningitis may be the first manifestation. Isotope cisternography and metrizamide CT cisternography are the most important methods for precise localization, sometimes also for verification of a suspected fistula. Most traumatic CSF fistulas of the frontal and ethmoidal region have to be treated operatively. The method of choice is the transfrontal approach and the closure of the fistula opening using a pedicled pericranial flap or fascia lata graft. Most sphenoidal fistulas have to be treated by packing the sphenoidal sinus with muscle. The treatment methods of the rare spontaneous and symptomatic CSF fistulas are also described. The results of operative treatment are satisfactory. About 6% recurrences, which as a rule can be cured by reoperation, and a mortality rate of about 1-3% seem to be an acceptable price for prevention of an otherwise unavoidable and oftenly deadly meningitis. Future efforts are necessary to improve the operative technique in order to reduce the incidence of anosmia. Our descriptions and advice are based not only on literature reports but also on our own experiences with a combined material of 237 cases operated on for rhinorrhea.

Burr Hole Third Ventriculo-cisternostomy: An unpopular but effective procedure for treatment of certain forms of occlusive hydrocephalus

79 cases of obstructive hydrocephalus treated between 1972 and 1983 by burr hole third ventriculo-cisternostomy have been analysed together with the published literature. There were 80% good results in non-tumoral aqueduct stenosis and in hydrocephalus caused by pineal, posterior third ventricle or basal ganglia tumours. The results in hydrocephalus caused by dysrhapic malformations or following meningitis as well as in cases which previously had been treated by shunting procedure were unsatisfactory. Such cases therefore should be excluded from third ventriculo-cisternostomy. In the first mentioned cases the patency of the basal cisterns should be verified beforehand by CSF scintigraphy. Only cases with open cisterns should be selected for third ventriculo-cisternostomy. If these selection guidelines are followed good results can be expected in approximately 90%. Judging from the literature and from our own material the mortality rate is below 1% and the rate of transient neurological deficits about 5%. These complications seem to be avoidable by improved technique. The alternative methods used in the treatment of obstructive hydrocephalus, viz: ventriculo-cardiac or ventriculo-peritoneal shunting, have an overall complication rate higher than 50%. This comparison leads us to recommend third ventriculo-cisternostomy as the treatment of choice for properly selected cases of obstructive hydrocephalus.

Burr hole third ventriculo-cisternostomy

Summary79 cases of obstructive hydrocephalus treated between 1972 and 1983 by burr hole third ventriculo-cisternostomy have been analysed together with the published literature.There were 80% good results in non-tumoral aqueduct stenosis and in hydrocephalus caused by pineal, posterior third ventricle or basal ganglia tumours.The results in hydrocephalus caused by dysrhapic malformations or following meningitis as well as in cases which previously had been treated by shunting procedure were unsatisfactory. Such cases therefore should be excluded from third ventriculo-cisternostomy.In the first mentioned cases the patency of the basal cisterns should be verified beforehand by CSF scintigraphy. Only cases with open cisterns should be selected for third ventriculo-cisternostomy. If these selection guidelines are followed good results can be expected in approximately 90%.Judging from the literature and from our own material the mortality rate is below 1 % and the rate of transient neurological deficits about 5%. These complications seem to be avoidable by improved technique.The alternative methods used in the treatment of obstructive hydrocephalus, viz: ventriculo-cardiac or ventriculo-peritoneal shunting, have an overall complication rate higher than 50%. This comparison leads us to recommend third ventriculo-cisternostomy as the treatment of choice for properly selected cases of obstructive hydrocephalus.

Intracarotid infusion of ACNU and BCNU as adjuvant therapy of malignant gliomas. Clinical aspects and critical considerations.

SummaryThirty patients with malignant gliomas were treated by operation, radiotherapy and additional intracarotid infusions of ACNU and BCNU.Positive results were obtained in the treatement of oligodendrogliomas and astrocytomas grade III and IV. On the contrary, the results in cases of glioblastoma multiforme were disappointing: neither survival time nor quality of life had been significantly improved. The protective effect of phenobarbitone against systemic toxicity by ACNU was not always confirmed in this study.Based on literature reports and our own experience the indications, technical aspects, unexpected complications and results of this therapeutic approach are discussed.

Prognostic factors in the treatment of cerebellar haemorrhage

SummaryA prospective study for the treatment of cerebellar haemorrhage was conducted in a non-selected group of 33 patients. All patients with cerebellar haemorrhage arriving at the Department of Neurosurgery at Homburg/Saar have been included in this study, also those in bad condition, with high risk factors, and the aged. All of them required intensive care respectively intensive supervision.The following management protocol has been established.I.Cases with small haemorrhage, in good clinical condition, without hydrocephalus and/or occlusion of the basal cisterns: intensive supervision, operative intervention only if they deteriorate into one of the following groups.II.Cases with hydrocephalus — even if not yet pronounced — but without occluded basal cisterns and without major tonsillar herniation: pressure monitored ventricular drainage, which opens at 15 mm Hg and thus prevents higher CSF pressure developing.III. a):Cases with large haematoma, occluded basal cisterns and/ or tonsillar herniation, but without severe general risk factors, as a first step: pressure monitored ventricular drainage; as a second step, if they do not improve soon after the normalization of the ventricular pressure: open surgical evacuation of the haematoma, which also decompresses the posterior fossa. If present and possible, causative vascular malformations may be dealt with at the same session.III. b):Same intracranial situation, but patients with severe general risk factors: pressure monitored ventricular drainage only.IV.Cases with causative aneurysm or angioma, who initially had been treated conservatively or by ventricular drainage: secondary operation of the vascular malformation after stabilization of the general conditions. Overall mortality was 33%. For the 13 men — median age 58 (27–83) — the initial average Glasgow Coma Scale (GCS) grade was 9.2 and the median haematoma diameter 3.7 cm. For the 20 women — median age 53 (17–80) — the corresponding figures were 10.4 GCS and 3.4 cm.Of the 13 men 6 died (mortality 46%; total Karnofsky scale 37.6). Of the 20 women 5 died (mortality 25%; total Karnofsky scale 57.5).The worst prognosis related to patients with an additional intraventricular haemorrhage and men aged between 50 and 70 years with an admission GCS of less than 7 and occluded cisterns. Early loss of consciousness, additional ventricular bleeding, brain stem extension of the haemorrhage, occluded perimesencephalic cisterns and severe systemic disease — diabetes mellitus, liver cirrhosis from alcohol abuse with resulting coagulation disorders — were the main factors which led to unfavourable outcome.The results of our study, which are presented in detail in this paper, allow recommendations for our therapeutic strategy.

Surgical Approach to Lumbar Disc Herniations

The results of the operative treatment of lumbar disc prolapses depend not only upon operative technique and skill, the degree of radicular impairment and other facets of the patient’s condition but also upon the correct selection of cases for surgery.

Experimental investigation on the control of spinal cord circulation. IV. The effect of spinal or cerebral compression on the blood flow of the spinal cord.

SummaryIn experimental dwarf pigs compression of the spinal cord was carried out by applying different pressure with an epidurally located balloon. The circulation was measured in the compressed as well as in the neighbouring regions. The resulting data seem to indicate that, as well as the arterial circulatory disorders, disturbances of the venous out-flow are of major importance. Sudden pressure-rises within the region of the thoracic spinal cord have a cardio-vascular effect similar toCushings reflex in increased intracranial pressure. Intracranial pressure-increase leads to transient circulatory increase in the spinal cord. The results of our experiments are discussed in relation to the literature.

Acute changes in somatosensory evoked potentials following graded experimental spinal cord compression

Amplitude and latency of cortical somatosensory potentials evoked in cats by peripheral nerve stimulation were measured before, during, and for 5 hours after injury of spinal cord segment L-7 by a predetermined degree and duration of compression. An amplitude decrease, slight and transitory, was first observed after compression reduced the segmental cross section by 60%. After an 80% compression, amplitude reduction was initially larger and lasted longer, but recovered 2.5 hours after injury to a level that did not differ statistically from control values. After total (100%) compression, evoked responses disappeared abruptly and did not recover significantly. Latency was unaltered at all degrees of compression. Structural damage increased with the degree of compression. In this model, evoked potential changes neither reflect nor predict the magnitude of acute incomplete spinal cord injury.

Klinik und Behandlung der lumbalen Bandscheibenschäden

Zweifellos hat die neurochirurgische Behandlung der Bandscheibenvorfalle die Kenntnisse von Pathogenese und Symptomatologie der Lumbago und des Ischiassyndroms entscheidend gefordert. Dennoch gehoren diese Krankheitsbilder keineswegs ausschlieslich in die Hand des Neurochirurgen. Es ist vielmehr ein nur kleiner Anteil des Gesamtkrankengutes, der neurochirurgischer Therapie bedarf. Die Mehrzahl der Patienten wird mit konservativen Methoden befriedigend gebessert werden konnen, wobei je nach Schwere und Auspragung des Krankheitsbildes sich Hausarzt, Orthopade, Neurologe und Internist in die Behandlung teilen. Sieht man von schwerwiegenden motorischen Wurzelausfallen und Caudasyndromen ab, so ist es eine der wesentlichen Indikationen zur operativen Wurzelentlastung, das zuvor die konservativen Moglichkeiten ausgeschopft wurden.

Prospective comparative study of the effectiveness of epidural morphine and ropivacaine for management of pain after spinal operations.

Summary. Objective: Evaluation of the effectiveness of local application of morphine or ropivacaine for treatment of local and radicular pain after lumbar disc operations. Critical review of the literature about the possibilities of management of postoperative pain after spinal operations. Methods: A total of 113 patients were randomly given 5 mg morphine sulfate (N=42), 10 ml 0,25% ropivacaine (N=42) or physiological NaCl solution (N=21) locally after lumbar disc operation before wound closure. Postoperative lumbar and radicular pain was scored by the patients from 0 to 10 and registered on the evening of the day of operation and on the 1., 2., 3., and 5. days. Mean pain numbers of the 3 groups have been compared, subdivided into local lumbar and in radicular pain. Our own results have been compared with the results of reports in the literature. Results: In our own study the morphine group had less lumbar and less radicular pain on all 5 days than both of the two other groups. This difference was statistically significant on days 0, 1, 2, and 3. The ropivacaine group was on all days less effective than the morphine group, better than the placebo group on the operation and first day, but the difference against the placebo group was statistically not significant. Conclusion: Local application of 5 mg morphine sulfate is effective in prevention or reduction of postoperative lumbar and radicular pain after lumbar disc operations. Ropivacain is less effective. The routine application of epidural morphine at the end of spinal operations can be recommended. It also can be justified to try to prolong the morphine effect by mixing it into a paste as described by Needham and by Hurlbert, and to irrigate the operative field with ropivacaine at the end of the operation.