Ralph T. Schär

Patient-Rated Outcomes of Lumbar Fusion in Patients With Degenerative Disease of the Lumbar Spine: Does Age Matter?

Study Design. Single-center retrospective study of prospectively collected data, nested within the Eurospine Spine Tango data acquisition system. Objective. The aim of this study was to assess the patient-rated outcome and complication rates associated with lumbar fusion procedures in three different age groups. Summary of Background Data. There is a general reluctance to consider spinal fusion procedures in elderly patients due to the increased likelihood of complications. Methods. Before and at 3, 12, and 24 months after surgery, patients completed the multidimensional Core Outcome Measures Index. At the 3-, 12-, and 24-month follow-ups, they also rated the Global Treatment Outcome and their satisfaction with care. Patients were divided into three age groups: younger (≥50 years <65 years; n = 317), older (≥65 years <80 years; n = 350), and geriatric (≥80 years; n = 40). Results. A total of 707 consecutive patients were included. The preoperative comorbidity status differed significantly (P < 0.0001) between the age groups, with the highest scores in the geriatric group. Medical complications during surgery were lower in the younger age group (7%) than in the older (13.4%; P = 0.006) and geriatric groups (17.5%; P = 0.007); surgical complications tended to be higher in the elderly group (younger, 6.3%; older, 6.0%; geriatric, 15.0%; P = 0.09). There were no significant group differences (P > 0.05) for the scores on any of the Core Outcome Measures Index domains, Global Treatment Outcome, or patient-rated satisfaction at either 3-, 12-, and 24-months of follow-up. Conclusion. Despite greater comorbidity and complication rates in geriatric patients, the patient-rated outcome was as good in the elderly as it was in younger age groups up to 2 years after surgery. These data indicate that geriatric age needs careful consideration of associated risks but is not per se a contraindication for fusion for lumbar degenerative disease. Level of Evidence: 4

No Routine Postoperative Head CT following Elective Craniotomy – A Paradigm Shift?

Introduction Patient management following elective cranial surgery often includes routine postoperative computed tomography (CT). We analyzed whether a regime of early extubation and close neurological monitoring without routine CT is safe, and compared the rate of postoperative emergency neurosurgical intervention with published data. Methods Four hundred ninety-two patients were prospectively analyzed; 360 had supra- and 132 had infratentorial lesions. Extubation within one hour after skin closure was aimed for in all cases. CT was performed within 48 hours only in cases of unexpected neurological findings. Results Four-hundred sixty-nine of the 492 patients (95.3%) were extubated within one hour, 20 (4.1%) within 3 hours, and three (0.6%) within 3 to 10 hours. Emergency CT within 48 hours was performed for 43/492 (8.7%) cases. Rate of recraniotomy within 48 hours for patients with postoperative hemorrhage was 0.8% (n = 4), and 0.8% (n = 4) required placement of an external ventricular drain (EVD). Of 469 patients extubated within one hour, 3 required recraniotomy and 2 required EVD placements. Of 23 patients with delayed extubation, 1 recraniotomy and 2 EVDs were required. Failure to extubate within one hour was associated with a significantly higher risk of surgical intervention within 48 hours (rate 13.0%, p = 0.004, odds ratio 13.9, 95% confidence interval [3.11–62.37]). Discussion Early extubation combined with close neurological monitoring is safe and omits the need for routine postoperative CT. Patients not extubated within one hour do need early CT, since they had a significantly increased risk of requiring emergency neurosurgical intervention. Trial Registration ClinicalTrials.gov NCT01987648

Brainstem hemorrhage after neural therapy for decreased libido in a 31-year-old woman.

In September 2010, a 31-year-old otherwise healthy, female Caucasian consulted a dermatologist with additional qualifications in neural therapy because of decreased libido resistant to treatment. Following unproblematic procaine 1% injections at multiple gynecological and thyroidal sites, per os epipharyngeal injection was performed intending to infiltrate a neural therapy trigger point close to the pharyngeal tonsil at the anterior aspect of the sphenoid bone. This target point is assumed to represent remnants of the craniopharyngeal duct and Rathke’s pouch and is considered the source of various hormone imbalances [1]. Immediately after injection of 1 ml procaine, the patient developed right-sided brachiocrural hemiparesis, numbness of all limbs, nausea, vomiting, and rotatory vertigo. Approximately 30 min later, sensorimotor deficits gradually subsided, the vertiginous patient was reassured and sent home with an appointment set for the next day. Since the patient still complained about vertigo, nausea, and repeated vomitus on the following day, she was admitted to the emergency department of our hospital. At initial presentation, the patient was fully alert and orientated. The clinical examination was notable for positional vertigo in right lateral position and gaze-provoked upbeat nystagmus. Furthermore, a slight deficit in sensibility on the anterior aspect of the right lower leg was detected. The remainder of the clinical examination and all laboratory results were normal. Magnetic resonance imaging revealed a hemorrhagic lesion of 3 mm in diameter in the left paramedian medulla oblongata with slight perifocal edema (Fig. 1). Contrast-enhanced magnetic resonance angiography showed no evidence of any vertebral or intracranial artery dissection. Hereafter the patient was transferred to the intermediate care unit for further observation and was started on ceftriaxone and metronidazole to cover for possible contamination of the cerebrospinal fluid and brain by enoral microflora. She made an uneventful recovery, which allowed transfer to the neurology ward on the following day. Six days after admission, the patient was discharged from the hospital without a neurological deficit or subjective discomfort. To what extent the primordial desire was influenced by this experience was not ascertainable. Neural therapy was first described by Walter and Ferdinand Huneke in 1925 [1]. Although lacking scientific evidence, it is a widely used complementary medical method in Europe to treat acute and chronic pain syndromes, circulatory, autoimmune, and vegetative dysregulations [1]. Neural therapy uses injections of local anesthetics into or close to pathologically altered body regions such as scars, peripheral nerves, autonomic ganglia, glands, or other trigger points. Numerous adverse events have been reported following neural therapy, particularly when deep structures or internal organs were targeted [2–4]. So far, only one case of central nervous system hemorrhage has been reported. In 1979, Heyll and C. A. Schmittinger M. W. Dunser Department of Intensive Care Medicine, Inselspital, Bern Medical University, Bern, Switzerland

Intraoperative Ultrasound-Guided Posterior Cervical Laminectomy for Degenerative Cervical Myelopathy

OBJECTIVE We present our experience with routine intraoperative ultrasound (IOUS)-guided posterior cervical laminectomy (PCL) in patients with degenerative cervical myelopathy (DCM), describe the technique used, and describe relevant IOUS findings that may impact the surgical procedure. METHODS Three illustrative cases are presented of patients (age range, 67-79 years) who underwent PCL with IOUS guidance and instrumented fusion for DCM. Intraoperative standard B-mode images were obtained with a linear array 6.6- to 13.3-MHz transducer. RESULTS Excellent high-resolution IOUS view of the spinal cord and nerve roots was obtained in every case after laminectomy. IOUS had a relevant intraoperative impact in all cases, leading to extended decompression of focal residual compression, confirmation of posterior shift of the spinal cord from anteriorly located structures, and final confirmation of sufficient decompression by visualization of symmetric and rhythmic cord pulsations. CONCLUSIONS IOUS is a poorly described yet easy-to-use and very effective tool for guidance and confirmation of adequate posterior decompression of the cervical spinal cord and nerve roots during PCL. Routinely using IOUS-guided decompression for PCL in patients with myelopathy will help avoid residual compression of neural elements and might be beneficial for functional outcome.

Langerhans Cell Histiocytosis of the Adult Cervical Spine: A Case Report and Literature Review

&NA; A 36‐year‐old man was diagnosed with Langerhans cell histiocytosis (LCH) of the cervical spine with a unifocal expansive osteolytic lesion of C4. The surgical management with a 2‐year follow‐up and a review of the literature on LCH of the cervical spine are presented. Although a rare condition, LCH is an important differential diagnosis of any osteolytic lesion in the cervical spine with localized pain in a young adult patient. Review of the literature suggests a higher prevalence of LCH lesions affecting the cervical spine as compared with the thoracic or lumbar spine than historically reported.