Sergej Marasanov

Cervical Disc Replacement With Discover Versus Fusion In A Single Level Cervical Disc Disease: A Prospective Single Center Randomized Trial With A Minimum Two-Year Follow - Up.

Study Design: Prospective randomized study. Objective: To compare the clinical outcome after Discover arthroplasty versus anterior cervical discectomy and fusion (ACDF) in patients treated for symptomatic single-level cervical disk disease. Summary of Background Data: ACDF is still the gold standard for surgical treatment of cervical spine degenerative disk disease. However, results of many studies suggest that it may cause degenerative changes at levels immediately above and below the fusion, known as adjacent segment degenerative disease. Cervical arthroplasty has recently been introduced as an alternative to standard procedure of ACDF. It showed decreased surgical morbidity, decreased complications from postoperative immobilization, and an earlier return to previous level of function. Materials and Methods: A total of 105 consecutive patients with single-level cervical disk disease, producing radiculopathy and/or myelopathy were randomly divided into groups to undergo ACDF or Discover arthroplasty. All patients were evaluated with preoperative and postoperative serial radiographic studies and clinically, using Neck Disability Index, Visual Analog Scale and neurological status at 3, 6, 12, and 24 months. Results: The results of our study indicate that cervical arthroplasty using Discover Artificial Cervical Disc provides favorable clinical and radiologic outcomes in a follow-up period of 24 months. There has been significant improvement in clinical parameters, Visual Analog Scale and Neck Disability Index, at 3, 6, 12, and 24 months in arthroplasty group comparing to control group. Conclusion: The Discover artificial cervical disc replacement offers favorable outcome compared with ACDF for a single-level cervical disk disease at short-term and long-term follow-up.

Hypopituitarism after gamma knife radiosurgery for pituitary adenoma

ABSTRACT Purpose: The aim of the study was to investigate the incidence of and risk factors for hypopituitarism after gamma knife radiosurgery (GKRS) for pituitary adenoma. Materials and Methods: We conducted a retrospective analysis of the pituitary function of 90 patients who underwent GKRS for pituitary adenoma at the University Hospital Centre Zagreb between 2003 and 2014. Twenty seven of them met the inclusion criteria and the others were excluded from the study due to pituitary insufficiency which was present before GKRS. Eighteen patients had non-functioning and 9 patients had secretory adenomas. Median patients’ age was 56 years (24–82). GKRS was performed using the Leksell gamma knife Model C. The median prescription radiation dose was 20 Gy (15–25) and the median tumor volume size was 3.4 cm3 (0.06–16.81). New onset hypopituitarism was defined as a new deficit of one of the three hormonal axes (corticotroph, thyreotroph, or gonadotroph) ≥3 months following GKRS. SPSS was used for statistical analysis, with the significance level at P<0.05. Results: During the median follow-up period of 72 months (range 6–144), 30% of patients developed new hypopituitarism after GKRS. This corresponds to incidence of one new case of hypopituitarism per 15 patient-years. Age, gender, tumor function, tumor volume, suprasellar extension, prescription dose of radiation, as well as dose-volume to the pituitary gland, stalk and hypothalamus were not predictive factors for the development of hypopituitarism. Conclusions: In our cohort of patients with pituitary tumors who underwent GKRS, 30% developed new hypopituitarism during the follow-up period.

Combined Endovascular and Surgical Treatment of Spinal Dural Arteriovenous Fistulas

Introduction Type I spinal dural arteriovenous fistulas (SDAVFs) are the most common form of spinal vascular malformations. Even so, they are rare and still underdiagnosed. They are low-flow vascular shunts fed by radicular arteries in patients who most often present with myelopathy. Left untreated, they can lead to progressive neurological decline and considerate morbidity. We present our experiences and results in combined endovascular and surgical treatment of such lesions. Material and Methods We conducted a retrospective review of data from 14 adult patients with the diagnosis of SDAVFs who underwent treatment at University Hospital Center Rebro Zagreb between January 2012 and June 2014. We compared complication rates, recurrence rates and data on clinical and imaging follow up in these patients. Results 12 out of 14 patients underwent endovascular embolization (Onyx was used in 1 patients and NBCA in 11 patients) as the first line therapy. Two patients underwent surgical ligation as initial therapeutic modality. Patients in both groups showed significant improvement in clinical status after treatment (using the Aminoff-Logue Scale score). One patient in endovascular group developed spinal infarction due to accidental embolization of posterior spinal artery. Six patients in embolization group had recurrence of fistula during the course of follow up requiring surgical ligation. Two patients in surgical group had recurrence of fistula during the course of follow- up and were reoperated. Conclusion Despite most fistulas are amenable to endovascular embolization, microsurgical obliteration is the treatment of choice in specific anatomic situations and usually the only solution in recurrent cases. A combined approach offers the best results after careful selection of patients based on imaging.

Combined Endovascular and Surgical Treatment of Type I Spinal Dural Arteriovenous Fistulas

Introduction Spinal dural arteriovenous fistulas (SDAVFs) are rare but most common form of spinal vascular malformations, accounting for approximately 70% of all such lesions. They are low-flow vascular shunts fed by radicular arteries. Patients most often present with myelopathy. The presumed pathophysiological mechanism is venous hypertension and congestion of the cord with edema. We present our experiences and results in combined endovascular and surgical treatment of type I SDAVFs. Patients and Methods We conducted a retrospective review of prospectively collected data from patients with a diagnosis of SDAVFs who underwent treatment at University Hospital Centre Rebro Zagreb between January 2012 and June 2014. The complication and recurrence rates from clinical and imaging follow-up in these patients are analyzed. Results A total of 14 patients with a diagnosis of SDAVFs were treated in our institution during the analyzed period. Of these, 12 patients underwent endovascular embolization as first-line therapy. Onyx was used in 1 patient and NBCA in 11 patients. Two patients underwent surgical ligation as the initial therapeutic procedure. Patients in both groups showed significant improvement in clinical status after treatment on the Aminoff-Logue Scale. One patient in the endovascular group developed spinal infarction because of the accidental embolization of posterior spinal artery. Six patients in embolization group had recurrence of the fistula during the course of follow-up requiring surgical ligation. Two patients in the surgical group had recurrence of fistula during the course of follow-up and were reoperated. Conclusion Although most type I SDAFs are amenable to endovascular embolization, microsurgical obliteration as first option is indicated in specific anatomic situations and usually the only solution for recurrent cases. The combined endovascular and microsurgical approach offers best results after careful selection of patients based on imaging.

The Role of Intraoperative Neuromonitoring in Surgery of Lumbosacral Schwannomas: Five Years of Experience in a Single Center

Introduction Lumbosacral schwannomas are predominantly benign tumors arising from nerves within the spinal canal. Being one of the most common intradural extramedullary tumors, spinal schwannomas comprise up to 30% of such lesions. Surgery is the primary treatment modality and after total resection recurrence is rare. We present our experiences and results with patients operated on lumbosacral schwannomas with the use of intraoperative neuromonitoring with evoked potentials (SSEP, MEP, muscle EMG, cauda mapping). Materials and Methods A retrospective review of prospectively collected data from patients with a diagnosis of lumbosacral schwannomas operated at University Hospital Centre Zagreb, Croatia, from January 2009 to May 2014 was performed. We analyzed preoperative and postoperative medical records, pathological findings, radiographic studies, and clinical outcome of patients treated surgically for lumbosacral schwannomas. Surgical outcome was compared with evoked potential changes during surgery for lumbosacral schwannoma that significantly differed from baseline values. Results In the analyzed period, 26 patients were operated on for lumbosacral schwannomas at our institution. Of these were 11 male and 15 female patients. Mean age was 49.8 years. There were 4 giant and 22 nongiant schwannomas. Giant spinal schwannoma was defined as a tumor that extends over two or more vertebral levels, erodes vertebral bodies, and/or extends into the extraspinal space disrupting myofascial planes. Low back pain and radiculopathy were the most common presenting symptoms, rarely associated with urinary incontinence. Nongiant schwannomas were treated using minimal invasive unilateral approach, while giant schwannomas were treated using laminoplasty technique. In all patients, intraoperative neuromonitoring with SSEP, MEP, and spontaneous EMG was performed. Postoperatively, 21 patients fully recovered from preoperative neurological symptoms at 6-month follow-up. In 12 patients, SSEP changes occurred during surgery that differ from baseline values but had no impact on outcome. Four patients had transient neurological worsening which was in concordance with intraoperative SSEP and EMG disturbance findings. Out of 26 tumors excised, 2 were malignant schwannomas. One of the patients with the diagnosis of malignant schwannoma had to be reoperated for recurrence and died 2 years later. One patient with giant schwannoma developed an intracranial epidural hematoma postoperatively. Conclusion Intraoperative multimodality (SSEP, EMG) monitoring properly used and understood is a useful tool in lumbosacral schwannoma surgery. It assists the surgeon through the procedure as a means of intraoperative guidance allowing for completeness and safety of tumor removal and as such can influence the surgical outcome.