Ondrej Bradac

Anterior interbody fusion of the cervical spine with Zero-P spacer: prospective comparative study-clinical and radiological results at a minimum 2 years after surgery.

Study Design. A prospective study. Objective. The aim of this study was to compare clinical and radiological efficacy of anterior cervical microdiscectomy and fusion done by the newly designed low-profile interbody spacer in cases of symptomatic cervical spine spondylosis. Summary of Background Data. There are basically 2 ways to provide interbody fusion in the degenerative cervical spine; the first is by way of an unanchored “stand-alone” bone graft or cage, and the second is with bone graft or a cage anchored with a plate. Both concepts have their own benefits as well as potential drawbacks. Low-profile angle-stable spacer Zero-P is an implant that can potentially limit the drawbacks of both these procedures. Methods. Prospective study collecting clinical and radiological data of 77 patients undergoing anterior cervical interbody fusion of 1 or 2 motion segments from C3–C7 was performed. Zero-P spacer was used in 44 patients (55 segments) and in 33 cases (41 segments), stabilization was done using interbody spacer and dynamic anterior cervical plate. Patients were followed a minimum of 2 years after surgery. Results. There was no significant difference in neck disability index values, presence of dysphagia (P = 0.308), and Cobb C values during follow-up (P = 0.051) between both groups. A significant difference in the first 2 values of Cobb S was found (P < 0.001), but the next course of Cobb S changes showed no difference in either group. No difference was found in the radiological stability during follow-up, and no revision surgery was done. Conclusion. The results of this study confirm biomechanical assumptions associated with the Zero-P spacer. Implantation of this new cage results in setting required biomechanical conditions in the treated segment that are comparable with those when the segment is treated with a dynamic plate. However, the potential of the mentioned implant to reduce the incidence of postoperative dysphagia was not proven on this sample of patients. Level of Evidence: 3

Comparison of 3 fusion techniques in the treatment of the degenerative cervical spine disease. Is stand-alone autograft really the "gold standard?": prospective study with 2-year follow-up.

Study Design. A prospective study. Objective. The aim of this study was to compare the 3 different methods of interbody fusion of the cervical spine—autograft in stand-alone technique, autograft with anterior plate, and polyetheretherketone cage supported by anterior plate. The clinical and radiological data obtained were analyzed and discussed. Summary of Background Data. Although degenerative cervical spine disease has been treated by an anterior approach for more than 50 years, there is not one generally accepted operative approach. There is a very low-quality evidence of little or no difference in pain relief between each of the techniques. Iliac crest autograft still seems to be the “gold standard” for interbody fusion. Methods. Prospective study collecting clinical and radiological data of 81 patients undergoing anterior cervical interbody fusion, in which the interbody fusion of 1 or 2 motion segments from C3 to C7 was done by any of the 3 techniques–-stand-alone insertion of autograft (group 1: 28 patients), autograft and anterior plate (group 2: 18 patients), and polyetheretherketone cage filled with beta-tricalcium phosphate and plate (group 3: 29 patients). Patients were followed for 2 years after surgery. Results. Significant interaction of relative height in the segment and time was found (P < 0.001). The values of the relative height of stand-alone autograft dropped below 95% of initial height and the values of the other 2 groups remained above 105%. Significant interaction of time and group was found for Cobb S angles (P < 0.001). Values of group 1 decreased substantially and remained significantly lower than values of other 2 groups. Fusion rate was 100% in all groups. Neck Disability Index group and time interaction was found (P = 0.023). During postoperative follow-up, group 1 scored in all controls higher than the other 2 groups, but differences were not significant. Visual analogue scale showed effect of time (P < 0.001). This was due to a smaller improvement of patients in group 1 during the whole follow-up in comparison with the other 2 groups. Highest proportion of unsatisfied patients was in group 1 compared with the other 2 groups after 2 years (P = 0.034). Conclusion. Significantly worse radiological and clinical results after 2 years of follow-up were achieved using stand-alone autograft technique in comparison with autograft supported by anterior plating similarly as in comparison with cage implant and anterior plating. Using artificial fusion substrate together with plate and cage can offer the same clinical and radiological results such as iliac autograft and plating. Anterior plating seems to be an important factor influencing the postoperative cervical spine alignment and also the clinical outcome.

Hyperfamiliarity in patients with temporal lobe epilepsy

Hyperfamiliarity is a type of paramnesia characterized by an increased feeling of familiarity to unfamiliar faces. This dysfunction has been associated with frontal and temporal lobe pathology. The study investigated hyperfamiliarity in patients with temporal lobe epilepsy (TLE) by assessing their ability to recognize both familiar and unfamiliar faces. We evaluated 61 patients with pharmacoresistant TLE (33 right-sided, 28 left-sided) and 16 controls. The ability to recognize familiar faces was similar in patients and controls, although patients with left-sided TLE showed poorer performance in familiar face naming compared to both right-sided TLE patients and controls. Hyperfamiliarity was observed in a significantly higher number of patients with TLE compared to controls; in subgroup analysis, only right-sided TLE patients expressed hyperfamiliarity. Overall, patients with right-sided TLE showed more severe impairment compared to patients with left-sided TLE. It is proposed that hyperfamiliarity can be a relatively common symptom in patients with treatment-refractory TLE and right-sided focus.

Influence of the Preoperative Neurological Status on Survival After the Surgical Treatment of Symptomatic Spinal Metastases With Spinal Cord Compression.

Study Design. Consecutive case-series. Objective. The main purpose of this study was to analyze the relationship between the preoperative neurological status and subsequent survival of patients undergoing surgical treatment for symptomatic spinal metastases. Summary of Background Data. The survival of cancer patients has increased over recent years with improvements in oncologic therapy. As many as 70% of cancer patients develop spinal metastases and ∼10% of all cancer patients are treated for metastatic spinal cord compression. Methods. We retrospectively analyzed 166 patients who underwent surgery for symptomatic spinal metastases in our department between 2005 and 2012. The evaluated factors were age, primary tumor aggressiveness (slow, moderate, rapid growing), spinal location (cervical, thoracic, lumbar, and sacral), operation type (posterior decompression, anterior or posterior instrumented procedure, and radical combined instrumented surgery), preoperative evaluation using the revised Tokuhashi scoring system (<9, 9–11, and 12–15), pre- and postoperative neurological status according to the Frankel score (A-C and D-E), and the site of the main spinal cord compression (anterior, posterior, or combined). Postoperative complication and recurrence rate were also monitored. Results. The mean age of the patients was 62 ± 12 years. The median survival time after surgery was 16.0 months. Preoperative neurological status influenced survival time significantly; the median survival was 5.1 months in Frankel A-C and 28.2 months in Frankel D-E (P < 0.001). Improvement on the Frankel scale did not influence the survival time (P = 0.131). When the patients’ age was <65 years this related to a significantly longer survival time (P = 0.046). The Tokuhashi score predicted patients survival independently (P < 0.001). The other factors had no statistical significance. Conclusion. The most important factors influencing postoperative survival time of these patients with symptomatic spinal metastases was the preoperative neurological condition and the Tokuhashi scoring system, which together represents a useful tool for planning the extent of surgical treatment.

Endonasal endoscopic pituitary adenoma resection: preservation of neurohypophyseal function.

OBJECTIVES In the past 10 years, endoscopic resection of pituitary adenomas has become an alternative to microsurgical resection with the additional advantage of increasing the patients postoperative comfort. This analysis explored whether endoscopic resection can reduce the risk of postoperative neurohypophyseal dysfunction. DESIGN We rated and compared the need to administer desmopressin during the first four postoperative days and with the need after a follow-up of at least 3 months (chronic administration). SETTING Three groups of patients were compared: Patients in group 1 were operated on microscopically. Patients in group 2 were operated on endoscopically. Patients in group 3 were operated on endoscopically with intraoperative magnetic resonance imaging (iMRI). PARTICIPANTS Group 1 was made up of 50 patients treated in 1999; group 2 comprised 50 patients operated on from 2006 to 2007; and Group 3 comprised 50 patients operated on in 2008. MAIN OUTCOME MEASURES In group 1 the need to use desmopressin postoperatively occurred in eight patients; three needed chronic treatment. In group 2 the need for postoperative application of desmopressin occurred in four patients; none required chronic treatment. In group 3 desmopressin had to be administered postoperatively in five patients but only temporarily. RESULTS AND CONCLUSIONS Endoscopic surgery is a safe and effective method for the resection of pituitary adenomas. The rate of chronic desmopressin application was reduced. In conjunction with iMRI and navigation, the endoscopic technique allows increased radicality together with fewer adverse effects.

E-WIN Project 2016: Evaluating the current gender situation in neurosurgery across Europe. An interactive, multiple-level Survey

BACKGROUND The proportion of women among neurosurgeons appears to be growing worldwide with time. Official data concerning the current situation across Europe have not yet been published. Thus, there are still concerns about gender inequality. The European Women in Neurosurgery Project 2016 was designed to recognize the current situation across Europe. METHODS The office holders of the national neurosurgical societies of 39 countries forming the European Association of Neurosurgical Societies were contacted to provide data stating the proportion of women in neurosurgery. Obtained data were supplied with the results of an online survey. RESULTS The response rate of national office holders was 90%. The number of reported neurosurgeons was 12,985, and overall proportion of women represented was 12%. Two hundred thirty-seven responses to online questionnaire were taken into account. The overall proportion of female respondents was 30%. There was no intergender variability in responses regarding amount of working time per week, exposure to surgeries, or administrative work. Male respondents reported dedicating significantly more time to scientific work and feeling more confident dictating own career direction. Female respondents reported being less often married, having fewer children, a stronger perception of gender significance level, and a higher appreciation of personal qualities. CONCLUSIONS Neurosurgery is a challenging field of medicine. The results of our survey did not imply an overall feeling of gender inequality among European respondents, although women believe that the gender issue to be more important than men do and that they have to sacrifice more of their personal lives.

The Impact of a Standardized Sodium Protocol on Incidence and Outcome of Dysnatremias in Neurocritical Care.

BACKGROUND Dysnatremias are common and prognostically serious in neurocritical care. We studied whether a standardized sodium protocol would improve our neurocritical care of dysnatremias. METHODS A 5-year prospective study of a standardized sodium protocol for 1,560 patients admitted with various brain diseases in an adult neurologic-neurosurgical intensive care unit (NNICU) was compared with a 5-year retrospective analysis of 1,440 patients without the sodium protocol. Hyponatremia was defined as serum sodium (SNa(+)) < 135 mmol/L and hypernatremia SNa(+ )> 150 mmol/L. The sodium protocol involved measuring SNa(+), serum, and urine osmolality, measured and calculated renal function parameters, fluid intake 40 mL/kg weight/day without hypotonic saline, thiazide, and desmopressin acetate in all normonatremic NNICU patients. RESULTS In the protocol study, hyponatremia occurred slightly less often (15.7 versus 16.3% of patients; p = 0.684), hypernatremia was significantly higher (respectively 8.5% versus 5.2% of patients; p < 0.001), and no differences were noted in hypo/hypernatremia (p = 0.483). There were no differences in the incidence of hypo-osmolal hyponatremia (respectively 3.5% versus 3.5% of patients; p = 0.987), cerebral salt wasting (CSW; respectively 1.7% versus 1.7% of patients; p = 0.883), syndrome of inappropriate secretion of antidiuretic hormone (SIADH; respectively 0.1% versus 0.3% of patients; p = 0.152), central diabetes insipidus (CDI; respectively 1.0% versus 0.6% of patients; p = 0.149). In hyponatremia there were no differences in the Glasgow Coma Scale (GCS) score upon onset of hyponatremia (p = 0.294), NNICU mortality (respectively 1.0% versus 0.4% patients; p = 0.074), and bad outcome upon discharge from NNICU (respectively 5.1% versus 6.5% of patients; p = 0.101), but in hypernatremia GCS score upon onset (p < 0.001), mortality (respectively 2.8% versus 1.0%; p < 0.001), and bad outcome from NNICU (respectively 6.7% versus 2.7% patients; p < 0.001) were significantly higher. Multivariate logistic regression analysis showed that hypernatremia, compared with hyponatremia, was a significant predictor of mortality during NNICU stay (respectively odds ratio [OR]: 1.14; p = 0.003 versus OR; 5.3; p = 0.002). CONCLUSIONS The standard sodium protocol lowered the frequency of SIADH, which was encountered in only one patient over 5 years. However, it did not significantly reduce the incidence and improve the outcome of hyponatremia. Hypernatremia occurred more often and had a higher mortality and worse outcome than hyponatremia, but these patients were neurologically worse upon its onset. The prospective study confirmed that CSW, SIADH, and CDI were not common in our neurocritical care.

Low incidence of multidrug-resistant bacteria and nosocomial infection due to a preventive multimodal nosocomial infection control: a 10-year single centre prospective cohort study in neurocritical care

BackgroundNosocomial infection (NI) control is an important issue in neurocritical care due to secondary brain damage and the increased morbidity and mortality of primary acute neurocritical care patients. The primary aim of this study was to determine incidence of nosocomial infections and multidrug-resistant bacteria and seek predictors of nosocomial infections in a preventive multimodal nosocomial infection protocol in the neurointensive care unit (NICU). The secondary aim focused on their impact on stay, mortality and cost in the NICU.MethodsA10-year, single-centre prospective observational cohort study was conducted on 3464 acute brain disease patients. There were 198 (5.7%) patients with nosocomial infection (wound 2.1%, respiratory 1.8%, urinary 1.0%, bloodstream 0.7% and other 0.1%); 67 (1.9%) with Extended spectrum beta-lactamase (ESBL); 52 (1.5%) with Methicillin-resistant Staphylococcus aureus (MRSA), nobody with Vancomycin-resistant enterococcus (VRE). The protocol included hygienic, epidemiological status and antibiotic policy. Univariate and multivarite logistic regression analysis was used for identifying predictors of nosocomial infection.ResultsFrom 198 NI patients, 153 had onset of NI during their NICU stay (4.4%; wound 1.0%, respiratory 1.7%, urinary 0.9%, bloodstream 0.6%, other 0.1%); ESBL in 31 (0.9%) patients, MRSA in 30 (0.9%) patients. Antibiotics in prophylaxis was given to 63.0% patients (59.2 % for operations), in therapy to 9.7% patients. Predictors of NI in multivariate logistic regression analysis were airways (OR 2.69, 95% CI 1.81-3.99, p<0.001), urine catheters (OR 2.77, 95% CI 1.00-7.70, p=0.050), NICU stay (OR 1.14, 95% CI 1.12-1.16, p<0.001), transfusions (OR 1.79, 95% CI 1.07-2.97, p=0.025) antibiotic prophylaxis (OR 0.50, 95% CI 0.34-0.74, p<0.001), wound complications (OR 2.30, 95% CI 1.33-3.97, p=0.003). NI patients had longer stay (p<0.001), higher mortality (p<0.001) and higher TISS sums (p<0.001) in the NICU.ConclusionsThe presented preventive multimodal nosocomial infection control management was efficient; it gave low rates of nosocomial infections (4.2%) and multidrug-resistant bacteria (ESBL 0.9%, MRSA 0.9% and no VRE). Strong predictors for onset of nosocomial infection were accesses such as airways and urine catheters, NICU stay, antibiotic prophylaxis, wound complications and transfusion. This study confirmed nosocomial infection is associated with worse outcome, higher cost and longer NICU stay.

Neuropsychological Performance after Brain Arteriovenous Malformations Treatment.

Background The treatment of brain arteriovenous malformations (AVMs) has been studied extensively. With the use of the Spetzler‐Martin (S‐M) grading system, patients can be informed appropriately about their possible surgical risks. This does not hold true for their neuropsychological sequelae, which have not been studied widely. We evaluated the neuropsychological outcome of our patients treated for brain AVMs. Methods Of 113 patients treated for a brain AVM between 2001 and 2009, 66 patients were enrolled in the study. All patients underwent treatment at our institution and neuropsychological testing 2 years later using a test battery constructed specifically for this study. A control group consisted of 10 subjects without any neurologic disease. Results When the whole cohort was analyzed, no significant differences were found between the groups distinguished by hemorrhage, gender, or hemispheric dominance. Patients with S‐M IV and V scores fared significantly worse than patients with S‐M I to III. Patients who presented with epilepsy scored lower than patients presenting with other symptomatology, but the difference had only borderline significance. When we analyzed patients according to the presence or absence of obliteration after treatment and compared these with the control group, we found no significant differences. When the patients with an obliterated AVM after treatment were subdivided according to treatment modality, there were no significant differences in their S‐M groups compared with the control group. Similarly, those patients with nonobliterated AVMs analyzed according to their S‐M grade showed a borderline significant difference, with S‐M IV and V having a worse neuropsychological outcome compared with the other groups. Conclusions Patients harboring nonobliterated high‐grade AVMs (S‐M IV and V) scored worse than patients with nonobliterated AVM S‐M grades I to III. This could be explained by the steal phenomenon. No differences in neuropsychological testing were found when comparing results according to nidus location. This study lends support to an active treatment policy for cerebral AVMs. Those patients in whom complete obliteration was achieved with treatment scored similarly to the background population, implying active AVM treatment does not cause deterioration in neuropsychological performance. This, together with a > 90% AVM obliteration rate, favors microsurgery as the treatment modality of choice whenever the AVM can be safely resected.

Brain death and potential organ donors in neurocritical care mortality

Methods We performed an analysis of a 10-year prospective observational cohort database of 6138 patients (58.2% of males, mean: age 55.9 ± 14.7 years, body weight 78.3 ± 15.6 kg, body mass index 26.9 ± 4.7, NICU stay 3.8 ± 5.3 days, Acute Physiology and Chronic Health Evaluation II score on admission 10.63 ± 5.2) admitted to a single adult neurointensive care unit (NICU). There were 3462 (56.4%) patients (pts) with brain disease (stroke 43.2%, tumour 31.1%, trauma 13.6%, epilepsy 3.8%, hydrocephalus 3.4%, infection 2.5%, others 2.2%), 10.3% of pts had internal carotid artery stenosis (ACI), 32.6% of pts had spine diseases and 0.7% of pts had other disorders. Mean Glasgow Coma Scale on admission was 13.79 ± 2.51 and Glasgow Outcome scale upon discharge from NICU 3.97 ± 1.13.