Theofilos G. Machinis

Results of long-term follow-up in patients undergoing anterior screw fixation for type II and rostral type III odontoid fractures.

Study Design. Retrospective analysis of the fusion rate of a group of 38 patients having undergone anterior screw fixation for type II and “shallow” type III odontoid fractures. Objective. To determine primarily the long-term fusion rate after anterior screw fixation and to study the clinical characteristics of patients that have a statistically significant or nonsignificant influence on successful outcome. Summary of Background Data. Long-term outcome of anterior screw fixation for odontoid fractures has been evaluated in very few studies. This information should be critical for further establishing this technique as a major therapeutic strategy for these cases. Methods. Thirty-eight patients, 25 males and 13 females (with mean age 48.4 ± 0.4 years), with type II and rostral type III odontoid fractures, underwent anterior cannulated screw fixation during a 62-month period. Radiologic examination of the cervical spine with plain radiographs was performed at 6 weeks, and 2, 6, 12, and 24 months, while computerized tomography of the upper cervical spine (C1–C3) was obtained at 6 months after surgery. Follow-up was available for 31 patients, and the follow-up time ranged from 39 to 87 months (mean 58.4). Results. Radiographic evaluation of the follow-up group showed satisfactory bony fusion and no evidence of abnormal movement at the fracture site in 27 (87.1%) patients. Pseudarthrosis developed in 4 (12.9%) patients; however, 3 (9.6%) of them without instability and 1 (3.2%) with instability. One (3.2%) patient had an instrumentation failure without instability. Conclusions. In our series, anterior odontoid screw fixation comprised a safe therapeutic modality with high stability and low mechanical failure rates during short-term and long-term follow-up.

Long-term surgical outcome in patients with intracranial hydatid cyst

SummaryBackground. Cerebral hydatid cysts account for up to 3.6% of all intracranial space-occupying lesions, in endemic countries. The vast majority of patients affected are children. Computed tomography (CT) and magnetic resonance imaging (MRI) have greatly contributed to a more accurate diagnosis of hydatids. However, correct pre-operative diagnosis still remains quite puzzling. Extirpation of the intact cyst is the treatment of choice, resulting in most cases to a complete recovery. Method. In our retrospective study, we have reviewed 76 cases of intra-cranial hydatid disease operated on in our hospital over a 22 year period. Presenting clinical symptoms and signs and the radiological findings on CT and MRI were documented. Albendazole was given preoperatively to patients with giant (>5 cm) or multiple cysts and postoperatively to all patients. The follow-up period ranged from 12 months to 22 years and the outcome was assessed using the Glasgow Outcome Scale (GOS). Findings. Sixty seven (95.7%) of our patients were children. Increased intracranial pressure and papilledema were the predominant findings in this group, whereas focal neurological deficits were most prevalent in adults. CT and MRI revealed round cystic lesions, isodense and iso-intense respectively to cerebrospinal fluid (CSF), with no rim enhancement or perifocal edema. Multiple cysts were identified in 3 cases. Extirpation of the cyst without rupture was accomplished in 56 patients (73.7%). Recurrences occurred in 19 patients (25%). 4 patients (5.3%) died within 6 months after surgery; 3 of these patients had multiple cysts and one died shortly after the operation due to anaphylactic shock following intra-operative rupture of the cyst. Conclusion. Long-term follow-up confirms that intracranial hydatid cysts should always be surgically removed without rupture; the outcome remains excellent in these cases. Correct preoperative diagnosis is vital for the successful outcome of surgery. A high index of suspicion is therefore required in endemic areas despite the availability of advanced neuro-imaging. Medical treatment with albendazole seems to be beneficial both pre- and post-operatively. Newer diagnostic methodologies, such as MR spectroscopy and MR diffusion weighted imaging, might lend themselves to the diagnosis of intracranial hydatid cysts.

Review of the literature regarding the relationship of rebleeding and external ventricular drainage in patients with subarachnoid hemorrhage of aneurysmal origin

Acute hydrocephalus is a well-documented complication of subarachnoid hemorrhage. The insertion of external ventricular drainage (EVD) has been the standard of care in the management of this complication, aiming primarily at immediate improvement of the clinical condition of these patients, making them more suitable candidates for surgical or endovascular intervention. In our current communication, we review the pertinent literature regarding the relationship of rebleeding and EVD. Several studies have implicated a significantly increased risk of rebleeding in patients with EVD, compared with patients without it. Abrupt lowering of the intracranial pressure could lead to rebleeding due to decreased transmural pressure or removal of the clot sealing the previously ruptured aneurysm. However, a variety of parameters that could affect the rebleeding rate, such as the timing of surgery, the timing and duration of drainage, the size of the aneurysm, as well as the severity of the initial hemorrhage, do not seem to have been adequately explored in the majority of these studies. In addition, a number of clinical trials have failed to provide evidence for the negative role of EVD in the development of rebleeding. Conclusively, further long-term multi-center studies are required in order to establish the exact nature of the relationship between EVD and rebleeding after aneurysmal subarachnoid hemorrhage.

Clinical implications of quantitative infrared pupillometry in neurosurgical patients.

Pupillometry has been widely employed in the evaluation of a large number of pathological conditions, including intracranial pathology. The recent introduction of a portable, user-friendly, infrared pupillometer (ForSite, NeurOptics Inc., Irvine, CA) has enabled the accurate and reproducible measurement of several pupillary parameters, such as maximum and minimum apertures, constriction and dilation velocities, and latency period. It should be noted that various clinical conditions, especially neurological and ocular diseases, as well as numerous medications, may interfere with the measurements. Furthermore, a number of physiological parameters, such as the intensity of retinal illumination, the level of patients alertness, the intensity of ambient light, as well as the time of day that the examination is performed may alter the obtained values. The potential implications of pupillometry in the clinical assessment of neurosurgical patients, including its complex relationship to intracranial pressure changes, mandate the undertaking of prospective clinical studies validating the clinical significance of this noninvasive, diagnostic modality.

Spontaneous resolution of acute cranial subdural hematomas

Acute cranial subdural hematoma (SDH) represents a common consequence of traumatic brain injury. The vast majority of acute SDHs larger than 10mm in thickness require immediate surgical evacuation. In rare occasions, however, spontaneous resolution may occur. In our current communication, we present four cases of spontaneous resolution of acute cranial SDH. Further more, the proposed theories explaining spontaneous resolution of acute SDH, as well as, clinical parameters and imaging characteristics that might predict such phenomenon, are also reviewed. The possibility of spontaneous resolution of an acute SDH, although remote, may impact the decision making process regarding the management of these patients under certain conditions.

Spinal hydatid disease, a rare but existent pathological entity : Case report and review of the literature

Spinal hydatid disease is a not uncommon cause of spinal cord compression in endemic countries; however, involvement of the epidural space with sparing of the vertebral column is rare. Early diagnosis and surgical decompression with total removal of the hydatid lesion, when possible, is generally considered the standard of care for this disease. The authors describe a case of massive epidural hydatid disease without involvement of the vertebral column in a 62-year-old male patient, treated with a 2-stage surgical operation and administration of systemic albendazole. The literature is reviewed regarding the clinical features, diagnosis, treatment and prognosis of spinal echinococcosis.

Pain outcome and vertebral body height restoration in patients undergoing kyphoplasty.

Introduction: Kyphoplasty, a minimally invasive technique, has recently been developed to provide immediate pain relief, biomechanical stabilization, prevention of fracture progression, vertebral height restoration, and prevention or reversal of kyphosis to patients with osteoporotic vertebral compression fractures (VCF). Materials and Methods: We retrospectively reviewed 24 patients treated with kyphoplasty. A total of 37 vertebral levels were augmented. Visual analog scale (VAS) scores were documented in the immediate pre- and postoperative period, as well as 4, 12, and 72 weeks after the procedure. Vertebral body height restoration was assessed on postoperative x-rays. Results: Mean preoperative VAS score was 9.3 and improved to 5.4 in the immediate postoperative period. At 4, 12 and 72 weeks postoperatively, mean VAS scores were 5.1, 5.9, and 6.1 respectively. All patients returned to their daily activities within 24 hours. No significant restoration of vertebral body height was observed. Conclusion: In regards to pain relief and postoperative functional outcome, kyphoplasty is a safe and effective treatment modality for osteoporotic VCFs, even when no significant restoration of vertebral body height is achieved.

Surgical treatment of acute type II and rostral type III odontoid fractures managed by anterior screw fixation.

Objectives: In the present study, the authors comment on their experience with anterior odontoid screw fixation in the management of odontoid fractures, in an attempt to further assess the safety and the efficacy of this procedure. Materials and Methods: A retrospective analysis of 50 consecutive patients with reducible type II or rostral type III odontoid fractures, operated at our hospital with anterior odontoid screw fixation. Radiographic bony fusion, complications, and clinical outcome were evaluated. Results: Solid bony fusion was evident in 38 (90.5%) of the patients. One mechanical instrumentation-related complication occurred, without clinical significance. No other major complications related to the procedure were noted. A satisfactory range of motion in the cervical spine was observed in all patients. Conclusions: Anterior odontoid screw fixation is a safe and effective procedure for the treatment of type II and rostral type III odontoid fractures. Compliance to the specific indications and contraindications of this operation is crucial for optimal outcome.

Head Injury Management Algorithm as Described in Hippocrates' “Peri ton en cephali traumaton”

HIPPOCRATIC WORKS LEND themselves still today to the modern physician for further analysis of his approach to the diagnosis and treatment of various pathological conditions. We present an attempt to systematize his methodology regarding the management of head trauma and present it in the format of a modern-era algorithm.

C-reactive protein might predict outcome in aneurysmal subarachnoid haemorrhage

Inflammatory mechanisms have been implicated in the pathogenesis of cerebral vasospasm. C-reactive protein (CRP) represents a sensitive inflammatory marker. The purpose of our current study was to examine the relationship between CRP and the outcomes of patients sustaining aneurysmal subarachnoid haemorrhage (SAH).