J. Walter

PEEK cages as a potential alternative in the treatment of cervical spondylodiscitis: a preliminary report on a patient series

The surgical management of cervical spondylodiscitis consists of the resection of the affected disc, the decompression of the cervical spinal cord, followed by the stabilization using an autologous bone graft or a titanium implant combined with a ventral plate fixation. Until now, there were no studies about the practicability and putative safety of PEEK cages in cervical spine infection. Now, we present the history of five patients suffering from neurological deficits and septicemia caused by mono- or bisegmental pyogenic cervical discitis and intraspinal abscess without severe bone destruction. Patients were treated surgically by discectomy, decompression, and ventral spondylodesis. The disc was replaced by a PEEK cage without additional fixation. Progressive bony fusion and complete regression of the inflammatory changes was demonstrated 7–8xa0months later by a computer assisted tomography and contrast enhanced magnetic resonance imaging, respectively. The vertebral alignment changed minimally; the cages developed only a slight average subsidence. The clinical symptoms improved in all patients significantly. Neck pain or instability was never observed. Nevertheless, prospective investigations of a larger patient series are mandatory. We suppose that the use of PEEK cages represents a potential and safe alternative in the treatment of cervical spondylodiscitis in selected patients.

Operative treatment of subcortical metastatic tumours in the central region

The operative treatment of subcortical metastatic tumours within the paracentral area is still under discussion. Against the background of possible new postoperative neurological deficits and of evolving new radio oncological techniques, the indication for surgery is limited only to a subgroup of patients. In this retrospective study we present the clinical results after operative treatment of metastases within the central and paracentral brain region, with an emphasis on the short-term and mid-term functional outcome. We report on 20 patients suffering from subcortical brain metastases within the primary sensorimotor area, with a median volume on MRI-scans of 8.18xa0cm³. Patients were admitted to our department with a progressive hemiparesis (nxa0=xa011), focal seizures (nxa0=xa06) or other unspecific symptoms (nxa0=xa03) like headache, nausea, and neuropsychological disturbances, respectively. After updated MRI- and fMRI-scanning, intensive electrophysiological testing including MEP-brain mapping and interdisciplinary tumour-board discussion of each case, those patients were evaluated for surgery. Early postoperative control was done by MRI within the first 48xa0h. Follow-up took place in our outpatient department, assessing clinical criteria two and 6 weeks postoperatively, followed by clinical control and MRI-scans every 3 months. In all patients, surgery was performed under general anaesthesia, cranial neuro navigation and intraoperative motor cortex stimulation. Surgery and the early postoperative course were uneventful in all cases. After a 6 months follow-up, two patients had died. The motor deficits improved in seven patients and remained unchanged in four cases. One patient suffered from a new persistent hemiparesis. A temporary paresis occurred in two cases. In five patients there was no motor deficit pre- and postoperatively. The Karnofsky Performance Status improved in ten patients 6 months after surgery. Quality of Life, measured by the FACT-Br score, improved in 12 patients and remained unchanged in one patient. With modern techniques like fMRI-guided cranial neuronavigation and intraoperative neuromonitoring including direct stimulation of the motor cortex, microsurgical resection of subcortical paracentral metastases is feasible with an acceptable risk of neurological deterioration. Even preexistent deficits can improve with positive influence on the quality of life for oncological patients, being disabled by the symptoms caused by the cerebral lesion.

Neural cell adhesion molecule isoform 140 declines with rise of WHO grade in human gliomas and serves as indicator for the invasion zone of multiform glioblastomas and brain metastases

PurposeGliomas are highly invasive neuroepithelial tumors with a propensity of malignant transformation and very restricted treatment options. The neural cell adhesion molecule (NCAM) modulates cellular migration, proliferation, and synaptic plasticity by homophilic and heterophilic interactions. Hereby, we investigated its relevance as a glioma tissue marker for the biological aggressiveness of these tumors and compared these features with the carcinoma brain metastasis invasion zone.Materials and methodsWe analyzed 194 human brain samples. Human tumor-free brain specimens served as control for the white and gray matter. In addition to that, we used human glioblastomas from nude rats. All tissues were investigated immunohistochemically for the expression of the NCAM isoform 140. Additionally, the multiplanar MRI-CT fusion neuronavigation-guided serial stereotactic biopsy was performed and completed by histopathological workup.ResultsHuman gliomas loose NCAM-140 with the rise of their WHO grade. Meningiomas are NCAM-140 negative. As the most striking feature, human brain metastases and the majority of human glioblastomas of our patients and of nude rats were totally NCAM-140 negative. This NCAM negativity led us to the conclusion of three different main glioblastoma invasion patterns. Surprisingly, the majority of brain metastasis samples that contained surrounding brain parenchyma demonstrated invasive tumor cell nests beyond the sharply demarcated metastasis border. We also found invasive metastatic cell nests outside the contrast enhancing tumor zone by means of the MRI-CT fusion neuronavigation-guided serial stereotactic biopsy.ConclusionThe expression of NCAM-140 inversely correlates with the WHO grade of human gliomas. The lost expression of NCAM-140 in human glioblastomas and in brain metastases enables the investigation of the brain–tumor interface and the definition of glioblastoma invasion patterns and shows that brain metastases are more invasive than ever thought.

Multiplanar MRI-CT fusion neuronavigation-guided serial stereotactic biopsy of human brain tumors: proof of a strong correlation between tumor imaging and histopathology by a new technical approach

PurposeSerial stereotactic biopsy is a diagnostic procedure, used when open biopsy or tumor bulk removal seems to be associated with a too high risk of new neurological deficits in tumors of eloquent regions or tumors of deep localizations or in anticipated high surgery related morbidity even in the older patient group. Shortcomings of this method are recognized to be the missed pathohistological information from untargeted areas in heterogeneous tumors. This study shows for the first time a collection of patients with brain tumors with their associated multiplanar MRI–CT fusion imaging during stereotaxis and the histopathological features of serial tumor biopsies along exact trajectorial sites towards the tumor center.MethodsThirteen patients were included. Stereotactic biopsy was performed and neuronavigation was correlated to histopathological features.ResultsReactive tissue, endothelial hyperplasia, and diffusely scattered tumor cells occur outside the contrast-enhancing tumor in glioblastomas. Within the contrast-enhancing area, endothelial hyperplasia and diffuse tumor tissue were seen as compared to endothelial proliferations and the dense tumor as well as necroses in the image-defined center.ConclusionsSerial stereotactic biopsy is a reliable means. Strong correlations with the imaging characteristics of the lesions could be evaluated.

Expression of coagulation factors and their receptors in tumor tissue and coagulation factor upregulation in peripheral blood of patients with cerebral carcinoma metastases

BackgroundPatients with malignancies often suffer from thrombembolic events that complicate the course of cancer disease and reduce the patients’ quality of life or shorten the survival time in severe cases. This phenomenon is also known for patients with primary or secondary brain tumors; but the reasons are not identified.MethodsWe performed a prospective case-controlled study of patients with brain metastases but without any active peripheral tumor site. Blood of patients was collected perioperatively and investigated for coagulation factor activities. Moreover, we analyzed the expression of coagulation factors and their receptors within the tumor material of brain metastases from clear-cell renal cell carcinomas and small-cell carcinomas of the lung.ResultsHere, we show that even patients without an active peripheral tumor disease that means without any tumor masses outside the central nervous system after anticancer treatment by surgery, radiation therapy, or chemotherapy but with symptomatic brain metastasis develop an increased systemic activation of multiple coagulation factors. The pro-coagulatory state is expressed preoperatively, but also can be observed in the early postoperative period. Additionally to that, intracerebral metastases of clear-cell renal cell carcinomas and of small-cell carcinomas of the lung express prothrombin, thrombin, factor X, and the protease-activated receptors type 1, 2, 3, and 4.ConclusionsThese observations support the hypothesis of a link between the hemostatic system in the periphery and the malignant tumor disease even when the tumor is an intracerebral metastasis and the affected patient currently is free of a systemically active tumor. The results of this study support the hypothesis that the concerted action of coagulation factors and their receptors within the metastasis tissue itself and the systemic coagulation system could control the malignant behavior of tumor disease and make larger prospective trials mandatory.

Neuralgie des N. genitofemoralis nach Hernioplastik

ZusammenfassungDie periphere Nervenstimulation (PNS) hat sich in der Behandlung neuropathischer Schmerzen etabliert. In diesem Fall wird die erfolgreiche epifasziale Stimulation im Bereich des N.xa0genitofemoralis beschrieben. Dieser wurde durch eine endoskopische Hernioplastik alteriert. Es entwickelte sich eine ausgeprägte, therapierefraktäre Genitofemoralisneuropathie, die durch eine permanente PNS mit einer 8-poligen Stabelektrode behandelt wurde. Der Patient beschreibt im Ein-Jahres-Follow-up eine fast 70%ige Schmerzreduktion. Somit stellt die PNS eine Erfolg versprechende Therapieoption bei Neuralgien nach Hernioplastik dar.AbstractThe peripheral nerve stimulation (PNS) is an established therapy in the management of neuropathic pain. Here, we describe a case of successful epifascial stimulation in the proximity of the genitofemoral nerve, which was injured during an endoscopic hernioplasty. During the following months the patient developed an intense neuropathy of this nerve, which we now treated by permanent PNS with an 8-polar electrode. During the 1xa0year follow-up the patient described a pain reduction of nearly 70%. There were no adverse events until now. In conclusion, PNS is a promising procedure in the treatment of neuralgia after hernioplasty.The peripheral nerve stimulation (PNS) is an established therapy in the management of neuropathic pain. Here, we describe a case of successful epifascial stimulation in the proximity of the genitofemoral nerve, which was injured during an endoscopic hernioplasty. During the following months the patient developed an intense neuropathy of this nerve, which we now treated by permanent PNS with an 8-polar electrode. During the 1 year follow-up the patient described a pain reduction of nearly 70%. There were no adverse events until now. In conclusion, PNS is a promising procedure in the treatment of neuralgia after hernioplasty.

Pulmonary meningioma and neurinoma associated with multiple CNS tumours in a patient with neurofibromatosis type 2.

OBJECTIVEnNeurofibromatosis type 2 (NF2) is a common neurocutaneous disorder that exhibits an autosomal dominant inheritance, with a mutation at chromosome 22q12.2. Two forms can be distinguished: the Wishart-phenotype with an early and aggressive course and the Feiling-Gardner-phenotype with a less dramatic presentation. In general, patients present bilateral vestibular schwannomas, meningiomas and neurinomas of the central and peripheral nervous system as well as neurofibromas and gliomas. There is no reported case of pulmonary meningiomas and neurinomas associated with NF2 until now.nnnPATIENT AND METHODSnHere, we present a 16-year-old girl with NF-2 associated to CNS and pulmonary tumours and we discuss the case in the backlight of the literature.nnnRESULTSnThe reported patient presented a de novo NF2 germline mutation (R341X) and displayed the Wishart-type of NF-2 since she is 11 years old, with a huge anaplastic biparietal falx meningioma and a tentorium meningioma and a tumour-associated parietal mass as well as hypacusis starting at the infant age of 3 years. Multiple cranial and spinal tumours with extra- and intramedullary localization were also found. Moreover, recurrent pulmonary tumours developed and were classified as benign meningiomas and a single neurinoma. No direct evidence concerning a relationship between the pulmonary and cerebral tumours could be drawn.nnnCONCLUSIONnThis rare case extends our knowledge of NF2 and also raises interesting questions about the pathogenesis of meningiomas outside the CNS.

Neuralgia of the genitofemoral nerve after hernioplasty. Therapy by peripheral nerve stimulation

ZusammenfassungDie periphere Nervenstimulation (PNS) hat sich in der Behandlung neuropathischer Schmerzen etabliert. In diesem Fall wird die erfolgreiche epifasziale Stimulation im Bereich des N.xa0genitofemoralis beschrieben. Dieser wurde durch eine endoskopische Hernioplastik alteriert. Es entwickelte sich eine ausgeprägte, therapierefraktäre Genitofemoralisneuropathie, die durch eine permanente PNS mit einer 8-poligen Stabelektrode behandelt wurde. Der Patient beschreibt im Ein-Jahres-Follow-up eine fast 70%ige Schmerzreduktion. Somit stellt die PNS eine Erfolg versprechende Therapieoption bei Neuralgien nach Hernioplastik dar.AbstractThe peripheral nerve stimulation (PNS) is an established therapy in the management of neuropathic pain. Here, we describe a case of successful epifascial stimulation in the proximity of the genitofemoral nerve, which was injured during an endoscopic hernioplasty. During the following months the patient developed an intense neuropathy of this nerve, which we now treated by permanent PNS with an 8-polar electrode. During the 1xa0year follow-up the patient described a pain reduction of nearly 70%. There were no adverse events until now. In conclusion, PNS is a promising procedure in the treatment of neuralgia after hernioplasty.The peripheral nerve stimulation (PNS) is an established therapy in the management of neuropathic pain. Here, we describe a case of successful epifascial stimulation in the proximity of the genitofemoral nerve, which was injured during an endoscopic hernioplasty. During the following months the patient developed an intense neuropathy of this nerve, which we now treated by permanent PNS with an 8-polar electrode. During the 1 year follow-up the patient described a pain reduction of nearly 70%. There were no adverse events until now. In conclusion, PNS is a promising procedure in the treatment of neuralgia after hernioplasty.

Operative Therapie der bakteriellen Spondylodiszitis

ZusammenfassungEinleitungDie bakterielle Spondylodiszitis ist ein seltenes Problem in der Wirbelsäulenchirurgie. Mit dieser Studie möchten wir die Ergebnisse nach Operation unter besonderer Berücksichtigung von Ursachen, Vorgeschichte, Operation und Krankheitsverlauf untersuchen.MethodenEs handelt sich um eine retrospektive Studie über 53xa0Patienten basierend auf den Krankenakten, inklusive der laborchemischen und mikrobiologischen Befunde.ErgebnisseUnter neurologischen Ausfällen verschiedener Schweregrade vom umschriebenen sensiblen Defizit (n=1) bis hin zur Paraplegie (n=6) litten 29xa0Patienten. In Abhängigkeit von der befallenen Höhe und vom Ausmaß der Infektion wurde die Operation in 16xa0Fällen als reine Dekompression durchgeführt bzw. als ein- oder zweizeitige Dekompression mit ventraler oder dorsoventraler Stabilisierung. Staphylococcus aureus war der häufigste Erreger (n=23). Nach einem medianen Follow-up von 11,25xa0Monaten waren 3xa0Patienten verstorben. In 22xa0Fällen blieben die Patienten wegen Schmerzen oder neurologischer Ausfälle eingeschränkt.SchlussfolgerungBleibende neurologische Defizite und mögliche letale Komplikationen machen die Spondylodiszitis weiterhin zu einem Problem. Die Behandlung umfasst die gezielte antibiotische Therapie sowie die Operation in ausgewählten Fällen.AbstractObjectiveBacterial spondylodiscitis is a rare entity in spinal surgery. This study analyses the postoperative results of 53xa0patients, focusing on the history, the treatment, and the course of the disease.Material and MethodsThis retrospective study is based on the patients’ medical charts, including the laboratory and microbiological data.ResultsTwenty-nine patients suffered from different neurological deficits ranging from isolated mild hypaesthesia (n=1) to complete paraplegia (n=6). Depending on the affected area and the extension of the infection, surgery was done either as simple decompression in 16 cases or as decompression combined with a ventral or dorsoventral stabilization in 37 patients. Staphylococcus aureus was the most important triggering organism (n=23). After a median follow-up of 11.25 months, three patients had died, and 22 patients were still disabled because of persisting pain or neurological disturbances.ConclusionBecause of persistent neurological deficits and possible lethal complications, spondylodiscitis remains a severe problem. Management comprises targeted antibiotic therapy and surgery in selected cases.OBJECTIVEnBacterial spondylodiscitis is a rare entity in spinal surgery. This study analyses the postoperative results of 53 patients, focusing on the history, the treatment, and the course of the disease.nnnMATERIAL AND METHODSnThis retrospective study is based on the patients medical charts, including the laboratory and microbiological data.nnnRESULTSnTwenty-nine patients suffered from different neurological deficits ranging from isolated mild hypaesthesia (n=1) to complete paraplegia (n=6). Depending on the affected area and the extension of the infection, surgery was done either as simple decompression in 16 cases or as decompression combined with a ventral or dorsoventral stabilization in 37 patients. Staphylococcus aureus was the most important triggering organism (n=23). After a median follow-up of 11.25 months, three patients had died, and 22 patients were still disabled because of persisting pain or neurological disturbances.nnnCONCLUSIONnBecause of persistent neurological deficits and possible lethal complications, spondylodiscitis remains a severe problem. Management comprises targeted antibiotic therapy and surgery in selected cases.

[Operative therapy of bacterial spondylodiscitis: a retrospective study].

ZusammenfassungEinleitungDie bakterielle Spondylodiszitis ist ein seltenes Problem in der Wirbelsäulenchirurgie. Mit dieser Studie möchten wir die Ergebnisse nach Operation unter besonderer Berücksichtigung von Ursachen, Vorgeschichte, Operation und Krankheitsverlauf untersuchen.MethodenEs handelt sich um eine retrospektive Studie über 53xa0Patienten basierend auf den Krankenakten, inklusive der laborchemischen und mikrobiologischen Befunde.ErgebnisseUnter neurologischen Ausfällen verschiedener Schweregrade vom umschriebenen sensiblen Defizit (n=1) bis hin zur Paraplegie (n=6) litten 29xa0Patienten. In Abhängigkeit von der befallenen Höhe und vom Ausmaß der Infektion wurde die Operation in 16xa0Fällen als reine Dekompression durchgeführt bzw. als ein- oder zweizeitige Dekompression mit ventraler oder dorsoventraler Stabilisierung. Staphylococcus aureus war der häufigste Erreger (n=23). Nach einem medianen Follow-up von 11,25xa0Monaten waren 3xa0Patienten verstorben. In 22xa0Fällen blieben die Patienten wegen Schmerzen oder neurologischer Ausfälle eingeschränkt.SchlussfolgerungBleibende neurologische Defizite und mögliche letale Komplikationen machen die Spondylodiszitis weiterhin zu einem Problem. Die Behandlung umfasst die gezielte antibiotische Therapie sowie die Operation in ausgewählten Fällen.AbstractObjectiveBacterial spondylodiscitis is a rare entity in spinal surgery. This study analyses the postoperative results of 53xa0patients, focusing on the history, the treatment, and the course of the disease.Material and MethodsThis retrospective study is based on the patients’ medical charts, including the laboratory and microbiological data.ResultsTwenty-nine patients suffered from different neurological deficits ranging from isolated mild hypaesthesia (n=1) to complete paraplegia (n=6). Depending on the affected area and the extension of the infection, surgery was done either as simple decompression in 16 cases or as decompression combined with a ventral or dorsoventral stabilization in 37 patients. Staphylococcus aureus was the most important triggering organism (n=23). After a median follow-up of 11.25 months, three patients had died, and 22 patients were still disabled because of persisting pain or neurological disturbances.ConclusionBecause of persistent neurological deficits and possible lethal complications, spondylodiscitis remains a severe problem. Management comprises targeted antibiotic therapy and surgery in selected cases.OBJECTIVEnBacterial spondylodiscitis is a rare entity in spinal surgery. This study analyses the postoperative results of 53 patients, focusing on the history, the treatment, and the course of the disease.nnnMATERIAL AND METHODSnThis retrospective study is based on the patients medical charts, including the laboratory and microbiological data.nnnRESULTSnTwenty-nine patients suffered from different neurological deficits ranging from isolated mild hypaesthesia (n=1) to complete paraplegia (n=6). Depending on the affected area and the extension of the infection, surgery was done either as simple decompression in 16 cases or as decompression combined with a ventral or dorsoventral stabilization in 37 patients. Staphylococcus aureus was the most important triggering organism (n=23). After a median follow-up of 11.25 months, three patients had died, and 22 patients were still disabled because of persisting pain or neurological disturbances.nnnCONCLUSIONnBecause of persistent neurological deficits and possible lethal complications, spondylodiscitis remains a severe problem. Management comprises targeted antibiotic therapy and surgery in selected cases.