Wolfgang Börm

Patient satisfaction and disability after brachial plexus surgery.

OBJECTIVELittle is known about patient satisfaction and disability after brachial plexus surgery. Would patients undergo the procedure again, if they knew the current result beforehand? How do they rate their result and their disability? METHODSOf 319 plexus patients who had undergone surgery between 1995 and 2005, 199 received a 65-item questionnaire. Measurement instruments included a new plexus-specific outcome questionnaire (Ulm Questionnaire) with categories of satisfaction, functionality, pain, comorbidities, and work; and the disability of the arm, shoulder, and hand questionnaire (DASH; scale, 0–100). RESULTSOf 99 returned questionnaires, 70 were returned in a useful form for evaluation. The results of patients with C5–C6 lesions (21 of 70) are as follows: 90% (19 of 21) would undergo surgery again, 95% (20 of 21) were satisfied with the result, and 86% (18 of 21) subjectively improved. The mean DASH score was 41 (standard deviation [SD], 24). The results of patients with C5–C7 lesions (6 of 70) are as follows: 50% (3 of 6) were satisfied and would undergo surgery again, and 67% (4 of 6) improved. The mean DASH score was 46 (SD, 13). The results of patients with C5–T1 lesions (43 of 70) are as follows: 67% (29 of 43) would undergo surgery again, 81% (35 of 42) were satisfied, and 74% (32 of 43) reported improvement. The mean DASH score was 58 (SD, 26). The overall mean DASH score was 52 (SD, 26). Pain since the injury was prevalent in 86% of patients (60 of 70), back pain in 53%, and depression/anxiety in 21%. Fifty-two percent of those who worked before their injury (27 of 53 patients) remained unemployed or incapacitated for work. Forty-five percent of previous workers (24 of 53) returned to their former occupation. Occupational retraining was successful for 70% of patients (16 of 23). The mean duration until return to work was 9 months overall and 5 months for those who returned to their previous occupation. CONCLUSIONEighty-seven percent of patients were satisfied with the results and 83% would undergo the procedure again. Despite a high satisfaction rate, patients remained considerably disabled, and half of the previous workers did not return to work. Occupational retraining is effective.

Spinal hematoma unrelated to previous surgery: analysis of 15 consecutive cases treated in a single institution within a 10-year period.

Study Design. Retrospective clinical study. Objectives. To determine characteristics, treatment methods, and outcome in an institutional series of patients with spinal hematoma not related to previous surgery. Methods. The charts of all patients with spinal hematoma treated in our institution between January 1993 and December 2002 were reviewed and analyzed with regard to location and extension of the hematoma, duration of symptoms, neurologic status, diagnostic measures, therapy, and outcome. Results. Fifteen patients were identified with spinal hematomas not caused by previous spine surgery. There were 11 women and 4 men. One hematoma was located subdurally and another intramedullary. All other hematomas were extradural, with 10 spontaneous bleedings. Eight hematomas were located in the cervical, two in the cervicothoracic, and three in the thoracic region. Two others were situated in the lumbar spine. Mean extension was 4.7 segments (range, 2–8 segments). Mean interval between onset of symptoms and surgery was 18 hours (range, 8–48 hours) for 12 patients; in 2 cases, diagnosis was made after 17 and 36 days, respectively, and then treated by surgery. One patient was treated without operation. Operative treatment was accomplished in all cases by hemilaminectomy and/or interlaminar fenestration and hematoma evacuation, in those cases with a larger extension of extradural hematoma by an alternating hemilaminectomy, thus reducing the risk of postoperative instability. There was no recurrence. No correlation between time to surgery and outcome was found in this study group, but there was a strong correlation between initial neurologic status and outcome after surgery. Conclusions. Nonsurgical derived spinal hematomas are rare. In this series, most cases were spontaneous and located in the cervical or cervicothoracic region producing severe neurologic deficit and pain. Treatment should be surgical evacuation in the majority. As most hematomas are of great extension, alternating hemilaminectomy suffices for evacuation of extradural hematomas and supports the stability of the spinal segments. Outcome is highly dependent from initial neurologic status.

Surgical therapy of symptomatic arachnoid cysts - an outcome analysis.

Summary.Background. Arachnoid cysts may present with various symptoms and in different locations. Optimal treatment is still controversial, although cyst fenestration or shunt insertion are recognized as standard procedures. In this retrospective analysis the authors sought to determine which factors influence the outcome after surgery of symptomatic arachnoid cysts.Methods. 37 patients (24 male, 13 female, mean age 40.2 years) were treated within a ten year period in our institution. Mean follow-up was 39 months; follow-up was done on an ambulatory basis. For analysis patient charts were reviewed and cranial CT scans or MR investigations were examined to determine pre- and postoperative cyst volumes. Clinical outcome was graded into four subgroups using a scale based on the patients self-rating of success. Different factors were studied concerning their influence on outcome.Findings. Fenestration was performed in 28 cases, cysto-peritoneal or cysto-atrial shunting in 9 cases. A favourable outcome (subgroups 3 and 4) was achieved in 19 of 28 patients (fenestration) and in 6 of 9 patients (shunting), respectively. Mean reduction of the cyst volumes was 58% after fenestration and 74% after shunting revealing both methods to be effective. Degree of cyst volume reduction correlated significantly with clinical outcome. Patients with infratentorial cysts had more often a favourable outcome. Headache as the only symptom did not influence outcome.Conclusions. Surgery of symptomatic arachnoid cysts resulted in favourable outcome in two thirds of the patients. Both standard procedures, fenestration and shunting, are equally effective for treatment. Factors that influence outcome are the rate of volume reduction and cyst location.

Success of simple sequestrectomy in lumbar spine surgery depends on the competence of the fibrous ring: a prospective controlled study of 168 patients.

Study Design. Prospective controlled clinical study. Objective. The aim of this prospective nonrandomized study is to evaluate the recurrence rate and the clinical outcome of patients undergoing sole sequestrectomy and compare them with a standard treatment group. Summary of Background Data. While performing microsurgical disc excision, extruded disc fragments and loosened or degenerated parts of the nucleus are removed. It is controversial whether this strategy is always necessary. Within the literature, there is only little information about the results of exclusive sequestrectomy. Methods. Criteria for performing a sole sequestrectomy were a nonbulging disc and only small or medium perforations within the fibrous ring. According to these criteria, the authors recruited 90 patients for the sequestrectomy group. The control group was operated in standard microsurgical manner during the same time, including 84 patients. A detailed analysis of the actual pain status, the functional capacity (Hannover Activities of Daily Living Questionnaire, FFbH) and eventually additional spinal operations during the follow-up of 2 years was performed. Results. Mean Funktionsfragebogen Hannover (FFbH) score at the follow-up was 76% in the sequestrectomy group and 77.6% in the control group. This difference is statistically not significant. There were 2 recurrences in the sequestrectomy group at the same level and 1 postoperative instability requiring a fusion procedure. In the control group, there were 2 recurrences and 1 secondary lateral spinal stenosis that led to reoperations. The competence of the fibrous ring influenced significantly the success of a simple sequestrectomy. Conclusion. The sole sequestrectomy group revealed similar results compared with the standard microdiscectomy group. There is a comparable low number of recurrences in both groups. This is probably caused by the consequent selection of patients for sequestrectomy according to well-defined criteria.

Role of intraoperative neurophysiology in primary surgery for obstetrical brachial plexus palsy (OBPP)

ObjectiveManagement of conducting neuroma-in-continuity in primary surgery for obstetrical brachial plexus palsy (OBPP) is still discussed controversially. We present our experience with intraoperative neurophysiological recordings in the management of lesions in continuity in OBPP.MethodsA series of ten children with lesions in continuity of the upper brachial plexus is presented. Due to recordable compound nerve action potentials (CNAPs) and muscle response to motor stimulation across the neuroma, five children underwent external neurolysis of neuroma only (neurolysis group). Due to lack of recordable CNAPs or muscle response, resection of neuroma and interpositional nerve grafting were performed in another five children (resection and grafting group). Functional recovery after at least 30 months of follow-up was assessed.ResultsThere was a marked difference in functional recovery between the neurolysis and the resection and grafting group. Especially, recovery of shoulder function was disappointing after external neurolysis of conducting neuroma-in-continuity. At the end of follow-up, results of shoulder and elbow function after resection of neuroma followed by interpositional nerve grafting were better without exception.ConclusionIntraoperative neurophysiological recordings face certain difficulties when used in small children with OBPP. Due to overoptimistic assessment of prognosis after intraoperative CNAP recordings and motor stimulation, the functional results after neurolysis of conducting neuroma-in-continuity are disappointing. Resection of neuroma-in-continuity, conducting or not, offers the best opportunity for maximal functional recovery of the compromised upper limb in OBPP. The role of intraoperative neurophysiological techniques should be confined to the diagnosis of root avulsions.

Spinal tumors in coexisting degenerative spine disease--a differential diagnostic problem.

The clinical presentation of spinal tumors is known to vary, in many instances causing a delay in diagnosis and treatment, especially with benign tumors. Neck or back pain and sciatica, with or without neurological deficits, are mostly caused by degenerative spine and disc disease. Spinal tumors are rare, and the possibility of concurrent signs of degenerative changes in the spine is high. We report a series of ten patients who were unsuccessfully treated for degenerative spine disease. They were subsequently referred for operative treatment to our department, where an initial diagnosis of a tumor was made. Two patients had already been operated on for disc herniations, but without long-lasting effects. In eight patients the diagnosis of a tumor was made preoperatively. In two cases the tumor was found intraoperatively. All patients showed radiological signs of coexisting degenerative spine disease, making diagnosis difficult. MRI was the most helpful tool for diagnosing the tumors. A frequent symptom was back pain in the recumbent position. Other typical settings that should raise suspicion are persistent pain after disc surgery and neurological signs inconsistent with the level of noted degenerative disease. Tumor extirpation was successful in treating the main complaints in all but one patient. There was an incidence of 0.5% of patients in which a spinal tumor was responsible for symptoms thought to be of degenerative origin. However, this corresponds to 28.6% of all spine-tumor patients in this series. MRI should be widely used to exclude a tumor above the level of degenerative pathology.

[Neurogenic thoracic outlet syndrome. Long-term results of supraclavicular decompression].

ZusammenfassungEinleitung Das neurogene Thoracic-outlet-Syndrom (nTOS) ist wohl das umstrittenste Nervenkompressionssyndrom der oberen Extremität. Konservativ therapieresistente Beschwerden werden chirurgisch durch Dekompression der oberen Thoraxapertur über einen supraklavikulären Zugang, alternativ über eine transaxilläre Resektion der 1. Rippe behandelt. Ziel dieser Studie war, Langzeitergebnisse und operative Risiken des supraklavikulären Zugangs zu evaluieren.Material und MethodeDie retrospektive Langzeitstudie untersucht eine konsekutive Serie von 50 TOS-Operationen (bei 45 Patienten) über einen supraklavikulären Zugang. Alle Patienten wurden ambulant über mindestens 24 Monate nachuntersucht und abschließend einem standardisierten Telefoninterview unterzogen.Ergebnisse Die Therapierergebnisse unterliegen im Langzeitverlauf einer erheblichen sekundären Verschlechterung. Über einen Zeitraum von 24 Monaten verschlechterten sich 30% der Fälle. Auf lange Sicht sind 80% der Patienten durch den Eingriff gebessert (26% exzellent, 36% gut, 18% moderat). Die Komplikationsrate dieser Studie liegt bei 4,0%.SchlussfolgerungAufgrund von sekundären Verschlechterungen der Therapieergebnisse im Langzeitverlauf sind ausschließlich Langzeitstudien zur Evaluation der Behandlungsergebnisse bei nTOS sinnvoll. Die Behandlungsergebnisse der supraklavikulären Dekompression sind befriedigend, die Komplikationsrate gering.SummaryObjectives Neurogenic thoracic outlet syndrome (TOS) is one of the most controversial entrapment syndromes of the upper extremity. There are two different surgical approaches for its primary surgical treatment: supraclavicular decompression and transaxillary first rib resection. The aim of this study was to evaluate long-term results and surgical risks of the former.MethodsThis retrospective long-term study examines a series of 50 supraclavicular decompressions in 45 patients. Follow-up was for at least 24 months. All patients were reexamined regularly in nonstandardized fashion. Finally, each patient underwent a telephone interview with a standardized questionnaire.Results There was a significant deterioration of primary results during follow-up. About 30.0% of cases worsened within 24 months after operation. In the long run, about 80.0% of cases showed improvement of symptoms (26.0% excellent, 36.0% good, 18.0% moderate). The complication rate was 4.0%.Conclusion Due to secondary deterioration of treatment during follow-up, only long-term studies are suited for the examination of neurogenic TOS. Results after supraclavicular decompression are satisfactory, and the complication rate is low.

Neurogenes Thoracic-outlet-Syndrom@@@Neurogenic thoracic outlet syndrome: Langzeitergebnisse der supraklavikulären Dekompression@@@Long-term results of supraclavicular decompression

ZusammenfassungEinleitung Das neurogene Thoracic-outlet-Syndrom (nTOS) ist wohl das umstrittenste Nervenkompressionssyndrom der oberen Extremität. Konservativ therapieresistente Beschwerden werden chirurgisch durch Dekompression der oberen Thoraxapertur über einen supraklavikulären Zugang, alternativ über eine transaxilläre Resektion der 1. Rippe behandelt. Ziel dieser Studie war, Langzeitergebnisse und operative Risiken des supraklavikulären Zugangs zu evaluieren.Material und MethodeDie retrospektive Langzeitstudie untersucht eine konsekutive Serie von 50 TOS-Operationen (bei 45 Patienten) über einen supraklavikulären Zugang. Alle Patienten wurden ambulant über mindestens 24 Monate nachuntersucht und abschließend einem standardisierten Telefoninterview unterzogen.Ergebnisse Die Therapierergebnisse unterliegen im Langzeitverlauf einer erheblichen sekundären Verschlechterung. Über einen Zeitraum von 24 Monaten verschlechterten sich 30% der Fälle. Auf lange Sicht sind 80% der Patienten durch den Eingriff gebessert (26% exzellent, 36% gut, 18% moderat). Die Komplikationsrate dieser Studie liegt bei 4,0%.SchlussfolgerungAufgrund von sekundären Verschlechterungen der Therapieergebnisse im Langzeitverlauf sind ausschließlich Langzeitstudien zur Evaluation der Behandlungsergebnisse bei nTOS sinnvoll. Die Behandlungsergebnisse der supraklavikulären Dekompression sind befriedigend, die Komplikationsrate gering.SummaryObjectives Neurogenic thoracic outlet syndrome (TOS) is one of the most controversial entrapment syndromes of the upper extremity. There are two different surgical approaches for its primary surgical treatment: supraclavicular decompression and transaxillary first rib resection. The aim of this study was to evaluate long-term results and surgical risks of the former.MethodsThis retrospective long-term study examines a series of 50 supraclavicular decompressions in 45 patients. Follow-up was for at least 24 months. All patients were reexamined regularly in nonstandardized fashion. Finally, each patient underwent a telephone interview with a standardized questionnaire.Results There was a significant deterioration of primary results during follow-up. About 30.0% of cases worsened within 24 months after operation. In the long run, about 80.0% of cases showed improvement of symptoms (26.0% excellent, 36.0% good, 18.0% moderate). The complication rate was 4.0%.Conclusion Due to secondary deterioration of treatment during follow-up, only long-term studies are suited for the examination of neurogenic TOS. Results after supraclavicular decompression are satisfactory, and the complication rate is low.

Neurogenes Thoracic-outlet-Syndrom

ZusammenfassungEinleitung Das neurogene Thoracic-outlet-Syndrom (nTOS) ist wohl das umstrittenste Nervenkompressionssyndrom der oberen Extremität. Konservativ therapieresistente Beschwerden werden chirurgisch durch Dekompression der oberen Thoraxapertur über einen supraklavikulären Zugang, alternativ über eine transaxilläre Resektion der 1. Rippe behandelt. Ziel dieser Studie war, Langzeitergebnisse und operative Risiken des supraklavikulären Zugangs zu evaluieren.Material und MethodeDie retrospektive Langzeitstudie untersucht eine konsekutive Serie von 50 TOS-Operationen (bei 45 Patienten) über einen supraklavikulären Zugang. Alle Patienten wurden ambulant über mindestens 24 Monate nachuntersucht und abschließend einem standardisierten Telefoninterview unterzogen.Ergebnisse Die Therapierergebnisse unterliegen im Langzeitverlauf einer erheblichen sekundären Verschlechterung. Über einen Zeitraum von 24 Monaten verschlechterten sich 30% der Fälle. Auf lange Sicht sind 80% der Patienten durch den Eingriff gebessert (26% exzellent, 36% gut, 18% moderat). Die Komplikationsrate dieser Studie liegt bei 4,0%.SchlussfolgerungAufgrund von sekundären Verschlechterungen der Therapieergebnisse im Langzeitverlauf sind ausschließlich Langzeitstudien zur Evaluation der Behandlungsergebnisse bei nTOS sinnvoll. Die Behandlungsergebnisse der supraklavikulären Dekompression sind befriedigend, die Komplikationsrate gering.SummaryObjectives Neurogenic thoracic outlet syndrome (TOS) is one of the most controversial entrapment syndromes of the upper extremity. There are two different surgical approaches for its primary surgical treatment: supraclavicular decompression and transaxillary first rib resection. The aim of this study was to evaluate long-term results and surgical risks of the former.MethodsThis retrospective long-term study examines a series of 50 supraclavicular decompressions in 45 patients. Follow-up was for at least 24 months. All patients were reexamined regularly in nonstandardized fashion. Finally, each patient underwent a telephone interview with a standardized questionnaire.Results There was a significant deterioration of primary results during follow-up. About 30.0% of cases worsened within 24 months after operation. In the long run, about 80.0% of cases showed improvement of symptoms (26.0% excellent, 36.0% good, 18.0% moderate). The complication rate was 4.0%.Conclusion Due to secondary deterioration of treatment during follow-up, only long-term studies are suited for the examination of neurogenic TOS. Results after supraclavicular decompression are satisfactory, and the complication rate is low.

Expert’s comment concerning Grand Rounds case entitled “Delayed post-operative tension pneumocephalus and pneumorrhachis” by D. C. Kieser et al. (Eur Spine J, 2017; DOI 10.1007/s00586-017-5268-3)

causes neurological deterioration is important and early therapy is indicated. Otherwise, even death can occur due to either compressive intracranial air accumulation or “brain sagging” caused by chronic intracranial hypotension. As spine surgeons should know, even intracranial hemorrhage is possible with uncontrolled spinal CSF loss [2, 3]. Therefore, a CT (or MRI) scan of brain and spine is essential for diagnosis. In either condition, closing the wound is the first key step, performing a controlled CSF drainage (if primary closure of the fistula is not possible) without the possibility of additional air intake was the next. In cases with true intracranial hypertension due to tension pneumocephalus, decompression via a burr hole and dura opening at the cranial site can eventually save life [4]. It remains uncertain in this case if there was a true tension pneumocephalus, as intracranial pressure was not evaluated. Even the contrary, an intracranial hypotension can cause the symptoms that were present in this case. Treatment as performed here is appropriate as long as early recovery is noted and no signs of life-threatening intracranial hypertension (e.g., pupil widening) occur. In every case of CSF leakage during spine surgery, the surgeon should try everything to close the leak at the same time to minimize risks like described in this case [5]. We all know that this will not be possible in all of our patients.