Johan van Loon

Long-term follow-up after interbody fusion of the cervical spine

The aim of this work was to add to the body of data on the frequency and severity of degenerative radiographic findings at adjacent levels after anterior cervical interbody fusion and on their clinical impact and to contribute to the insights about their pathogenesis. One hundred eighty patients who were treated by anterior cervical interbody fusion and who had a follow-up of >60 months were clinically and radiologically examined by independent investigators. For all patients, the long-term Odom score was compared with the score as obtained 6 weeks after surgery. For myelopathic cases, both the late Nurick and the Odom score were compared with the initial postoperative situation. For the adjacent disc levels, a radiologic “degeneration score” was defined and assessed both initially and at long-term follow-up. At late follow-up after anterior cervical interbody fusion, additional radiologic degeneration at the adjacent disc levels was found in 92% of the cases, often reflecting a clinical deterioration. The severity of this additional degeneration correlated with the time interval since surgery. The similarity of progression to degeneration between younger trauma patients and older nontrauma patients suggests that both the biomechanical impact of the interbody fusion and the natural progression of pre-existing degenerative disease act as triggering factors for adjacent level degeneration.

Long-term results after anterior cervical fusion and osteosynthetic stabilization for fractures and/or dislocations of the cervical spine

This study presents the 5-9-year follow-up after anterior cervical fusion and osteosynthetic stabilization anterior plating for fractures and/or dislocations of the cervical spine in 25 patients. Adequate bony fusion was obtained in all patients within 1 year postoperatively. There were no problems of late screw loosening. Fracture of the osteosynthetic plate occurred in one patient. Late degenerative changes of the cervical spine at the disc levels adjacent to the fusion area were radiologically detected in 15 of the 25 patients (60%) and were related to the following situations: fusion on more than one disc level, fusion on a lower cervical segment, Frankel class A-C at admission, and hyperflexion injuries. However, these late degenerative changes had no subjective or clinical repercussions, at least until now. From a neurological point of view all patients remained stable postoperatively and no patients had late deterioration.

Ictal perfusion patterns associated with single MRI-visible focal dysplastic lesions: implications for the noninvasive delineation of the epileptogenic zone.

Summary:  Background: Invasive electroencephalogram (EEG) studies are often considered necessary to localize the epileptogenic zone in partial epilepsies associated with focal dysplastic lesions (FDL). Our aim was to evaluate the relationships between subtraction ictal SPECT coregistered with magnetic resonance imaging (MRI) (SISCOM) hyperperfusion clusters and MRI‐visible FDL, and to establish a preliminary algorithm for a noninvasive presurgical evaluation protocol for MRI‐visible FDLs in patients with refractory epilepsy.

Postoperative spiral computed tomography and magnetic resonance angiography after aneurysm clipping with titanium clips

OBJECTIVE To reduce morbidity and mortality after subarachnoid hemorrhage, it is imperative to evaluate the results of the surgical treatment of cerebral aneurysms. We investigated the usefulness of spiral computed tomography (CT) and magnetic resonance angiography as postoperative control examinations after cerebral aneurysms were clipped with titanium clips. METHODS Eleven patients with 13 treated aneurysms were studied prospectively with postoperative digital subtraction angiography, spiral CT, and magnetic resonance angiography. The occlusion of the dome of the aneurysm, the presence of a remnant of the neck, the patency of the parent vessels and other major vessels, and the presence of vasospasm were investigated. RESULTS The different parameters could all be well evaluated by postoperative spiral CT. The artifacts caused by the titanium clips, although relatively small compared with artifacts from other clips, precluded evaluating the dome and the neck of the aneurysm with magnetic resonance angiography. CONCLUSION In our opinion, spiral CT promises to become a valuable aid in in the postoperative evaluation of clipped aneurysms, and we recommend its routine performance. Postoperative digital subtraction angiography remains the gold standard and has to be performed when spiral CT reveals abnormalities, when the neck of the aneurysm cannot be evaluated because the clip overlays it, or when, intraoperatively, imperfect clipping is suspected and intraoperative angiography cannot be performed.

Longitudinal prospective long-term radiographic follow-up after treatment of single-level cervical disk disease with the Bryan Cervical Disc.

BACKGROUNDMany short- and intermediate-term radiological and clinical studies on cervical arthroplasty with the Bryan Cervical Disc have been published, providing, most of the time, satisfactory results. OBJECTIVETo prospectively assess the intermediate and long-term radiographic characteristics of disk replacement surgery with the Bryan Cervical Disc and to correlate these results with clinical outcome. METHODSRange of motion was measured with a validated tool. Intervertebral disk degeneration was assessed with a quantitative scoring system. Heterotopic ossification was evaluated with a previously published scoring system. Device stability was investigated by measuring subsidence and anteroposterior migration. General clinical patient outcome was assessed with the Odom classification system. RESULTSEighty-nine patients were initially included in this prospective long-term study. One patient was reoperated on at the index level and 4 were reoperated on at an adjacent level; those patients were not further analyzed. The mobility at the treated level was preserved in ≥ 85% of our cases. The insertion of the prosthesis did not lead to an increase in mobility at the adjacent levels. The degeneration score increased at both adjacent levels. Heterotopic ossification was present in 34% to 39% of the patients, depending on the follow-up point. No cases of anteroposterior migration or subsidence were found. More than 82% of all patients had a good to excellent clinical outcome in the long run. CONCLUSIONThe device maintains preoperative motion at the index and adjacent levels, seems to protect against acceleration of adjacent-level degeneration as seen after anterior cervical discectomy and fusion, and remains securely anchored in the adjacent bone mass in the long run. Heterotopic ossification was frequently seen. The vast majority of all patients had a good to excellent clinical outcome.

Vagus nerve stimulation in children with drug-resistant epilepsy: age at implantation and shorter duration of epilepsy as predictors of better efficacy?

AIM To study the efficacy of vagus nerve stimulation (VNS) therapy in a highly drug-resistant childhood epilepsy patient group and to investigate the effect of age at implantation on efficacy. METHODS The efficacy of VNS treatment was analysed in a cohort of 70 patients with drug-resistant epilepsy. Both children with focal (n=16) and generalized epilepsies (n=54) were included. Age at implantation varied between 19 months and 25 years. RESULTS Overall, responder rate was 54% with 5.7% children becoming seizure-free. The only factor in our analysis that could predict good outcome was age at implantation. In the youngest group (<5 years), the responder rate was 77% and this group also included three of the four seizure-free children. These three seizure-free children were known to have tuberous sclerosis. There were no outcome differences between generalized and focal epilepsies. CONCLUSIONS Our single centre study confirms previous studies on the efficacy of VNS in children. A larger study using multivariate analysis to disentangle the contribution of different factors (such as age at implantation, aetiology, and epilepsy duration) is necessary to confirm our preliminary finding that younger age at VNS implantation might result in a better outcome.

Treatment of a giant basilar artery aneurysm with a bridging stent and subsequent coil occlusion of the stent: case report

OBJECTIVE AND IMPORTANCETo report the treatment of a symptomatic giant basilar artery aneurysm in a child. CLINICAL PRESENTATIONA 7-year-old girl presented with a 2-month history of progressive right hemiparesis caused by a huge fusiform aneurysm of the basilar artery with compression of the brainstem. INTERVENTION OR TECHNIQUEThe patient was treated with a bridging bare stent and occlusion of the stent lumen with detachable coils. CONCLUSIONThe patient experienced immediate total occlusion of the aneurysm with almost total recuperation after 1 year.