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:: E.J.N.S. Vol. 24 No.1, January 2009 :: |
Objective: To investigate the importance
of cerebral oxygenation parameters, estimated from the jugular venous
oxygen saturation (SjO2) and cerebral arteriovenous oxygen difference
(AVDO2), as a supportive monitoring and management variable to intracranial
pressure (ICP) and cerebral perfusion pressure (CPP), and its impact
on the final outcome in patients with severe traumatic brain injury.
Method: The
study included 43 patients of cohort successive cases with severe traumatic
brain injury admitted between December 2006 and April 2008, with a post-stabilisation
Glasgow Coma Score (GCS) ? 8. These were divided into two groups; one
group in which the patients were treated with ICP/CPP management alone
(ICP/CPP-guided group) and the other group in which the SjO2 and AVDO2
were measured in addition to the ICP/CPP and managed accordingly (Jugular
bulb variables-guided group).
Results: The jugular bulb variables-guided
group had a slightly better outcome (44% good outcome), as compared
to the ICP/CPP-guided group (33% good outcome), and a worse outcome
(67% poor outcome) was observed in the ICP/CPP-guided group as compared
to the other group (56% poor outcome).
Conclusion: Outcome from severe TBI is
better in patients undergoing management based on monitoring and management
of both cerebral oxygenation and ICP/CPP, than in patients subjected
to monitoring and management of ICP and CPP alone. Integration of monitored
variables allows cross-validation and artefact rejection, better understanding
of pathophysiology, and the potential to target therapy. Newer methods
for detecting regional areas of ischemia are also important in the management
of severe traumatic brain injury patients.
Objective: This study was designed to evaluate
the efficacy of surgical decompression in treatment of meralgia paresthetica.
Patients and Methods:
This study included 30 patients (18 females, 12 males) within age range
of 24-62 years presented with meralgia paresthetica with mean duration
of symptoms 29.3±5.4 months. All the patients were subjected to conservative
management for 6 months. 12 patients were not improved with conservative
treatment .9 patients (70%) underwent unilateral neurolysis of the lateral
femoral cutaneous nerve (LFCN), whereas 3 patients (25%) underwent bilateral
neurolysis of the LFCN. Surgical outcome was graded subjectively by each
patient postoperatively based on 0-5 pain intensity scale.
Results: The
mean follow-up period was 14 months; range: 6-24 months. Surgical outcome
was graded subjectively by each patient postoperatively based on 0-5 pain
intensity scale; 5 patients (41.7%) improved completely; 2 patients (16.7%)
significant improved; 1 patient (8.3%) temporary improved; 4 patients
(33.3%) not improved, (Table 7). For the 4 (33.3%) patients who did not
improve after surgical decompression, re-exploration with trans-section
of the LFCN was done (1case bilateral, 3 unilateral) & pain improved
completely in all patients.
Conclusion:
It could be concluded that neurolysis of the LFCN is an effective treatment
for meralgia paresthetica in properly selected patients & trans-section
of the LFCN is indicated for patients who did not improved after surgical
decompression.
Keywords: Neurolysis,
lateral femoral cutaneous nerve, meralgia paresthetica.
Background Context: Scoliosis is a three dimensional deformity of the spine with lateral curvature measuring more than 10° with vertebral rotation and frequently associated with hypokyphosis. Adolescent idiopathic scoliosis (A.I.S) is a relatively common disorder without known cause affecting about 1-3% of adolescents between the ages of 10 and skeletal maturity. Purpose: Analysis of the results and the efficacy of posterior instrumentation and fusion (P.I.F) using hybrid technique (transpedicular screws distally at the lumbar or lower thoracic spine and hooks proximally) for correction of scoliosis in three planes.
Study Design: This is a prospective study upon 40 patients with (A.I.S) underwent (P.I.F) using hybrid technique either solely or proceeded by anterior release and fusion with average two years follow up.
Methods: Immediate preoperative and serial postoperative radiographic and clinical assessment.
Results: The majority of the patients were girls with average age at time of surgery 14.5 years. 20 patients underwent (P.I.F) solely, while 20 patients underwent combined approaches. The mean preoperative Cobb angle was 58°. The mean percent correction was 70%. There were no deaths or neurological complications. Conclusions: (P.I.F) using hybrid technique is a reliable method in treating (A.I.S), with potential for excellent deformity correction with low complication rate.
Key Words: Idiopathic Scoliosis, spine deformity, surgical correction, hybrid technique.
Objectives: to evaluate various preoperative radiological and clinical data as prognostic factors for the postoperative neurological improvement after cervical laminectomy.
Methods: 30 patients with cervical spondylotic myelopathy were treated by cervical laminectomy. Functional and neurological statuses were assessed preoperatively and at the end of follow-up using the Japanese Orthopedic Association (JOA) scale. Age, preoperative duration of symptom, cervical curvature, JOA score and the antero-posterior (AP) diameter of the cervical spinal canal were assessed as specific indirect predictors of postoperative (PO) improvement as judged by postoperative JOA score.
Results: All patients passed smooth intra- and postoperative course and only 3 patients had temporary deterioration of their JOA score that improved within 3-weeks PO and one patient had permanent deterioration after initial improvement with a surgical failure rate of 3.3%. JOA scores were significantly improved in all patients and statistical analyses defined age and preoperative duration of symptoms as preoperative predictors of improvement and ROC curve analysis judged by the area under-curve (AUC) defined age and preoperative spinal canal AP diameter as the most specific predictors of improvement with AUC=0.862 and 0.828, respectively.
Conclusion: cervical laminectomy still has role in treating patients with cervical spondylotic myelopathy, and old age, long duration of preoperative symptoms and abnormal cervical curvature with narrow AP diameter predict less postoperative neurological improvement.
Key words: Cervical curvature; cervical spondylotic myelopathy; predictors for improvement
Objectives: This study aimed to illustrate the outcome of emergency surgical trans-sphenoidal treatment of pituitary apoplexy.
Patients & Methods: The study included 16 patients; 10 males and 6 females with mean age of 41.8±11.2 years and a mean duration since ictus of 8±2.8 days. One patient was deeply comatosed on admission and died prior to surgical interference. Ten patients had a picture suggestive of sudden bleeding with an acute episode of devastating headache, diminution of vision and/or ocular paralysis, while 6 patients presented with a clinical picture of uncomplicated pituitary adenoma. All patients underwent a detailed history taking, complete neurological examination and visual assessment and MRI and CT scanning. Surgery was conducted using the sublabial midline rhinoseptal trans-sphenoid approach in 7 patients and endoscopic trans-sphenoid in 6 patients (total 13 patients), while 2 patients were managed conservatively.
Results: Hemorrhagic necrosis was reported in 7 patients, liquefied hematoma in 4 patients and infracted tumor in 2 patients. Complete excision was possible in 8 patients, 2 patients had incomplete excision and no tumor tissue was encountered in 3 patients. All patients had smooth intra- and postoperative course and were followed-up for a mean duration of 25.4±9.5 months without morbidities or mortalities. Visual acuity was improved in 6 of 8 affected cases, visual field defects were improved in 4 of 6 cases and 3 of 9 cases had ocular muscle paralysis showed complete recovery. Pathological examination of the excised specimens revealed non-secreting pituitary adenomas in 7 cases, 3 prolactinomas and 3 GH secreting adenoma. Two specimens were of locally aggressive tumor and both patients received a postoperative course of radiotherapy.
Conclusion: It could be concluded that emergency surgery using the trans-sphenoidal approach is a feasible, safe and effective life saving therapeutic modality for the life-threatening condition "pituitary Apoplexy" providing high postoperative improvement rate without additional morbidities or mortality.
Objective: The aim of this study is to discuss the surgical outcome and the prognostic factors of intramedullary ependymomas with an associated syrinx, the clinical manifestations, the surgical treatment and patient outcomes.
Methods: In this study, a series of 22 cases of intramedullary ependymomas associated with syringomyelia were retrospectively analyzed. All patients were treated in the Neurosurgical Department Cairo University Hospitals from February 1999 to May 2007. Patients consisted of 12 males and 10 females with age ranging from 16 to 51 years with a mean age 38.8 years. The main presenting complaint was motor weakness followed by gait ataxia, pain, sensory deficit, dysthesias and sphineteric problems. Tumours were located in the dorsal region in 59%, in the cervical region in 36% and in the couns area in 5%. All patients were diagnosed via an MRI with gadolinium. The surgical treatment was discussed in details. We achieved total excision in 95.5% of the cases. Following surgery, we had transient worsening of motor power in 36% with gradual improvement. Pain showed direct improvement while sensory deficit and dysthesias showed the slowest improvement. Regarding complications, we had CSF leakage in 18%, wound infiction in 9%, DVT in 4.5% and gastrointestinal bleeding in 4.5%. There were no recurrent cases and the syrinx showed complete resolution in the follow up MR examination.
Conclusion: The presence of a syrinx accompanying intramedullary ependymomas is a favorable prognostic sign as it helps to achieve complete tumour excision. The syrinx automatically resolves gradually, complete tumour excision is the best prognostic factor in patients with intramedullary ependymomas.
Key Words: ependymoma . Intramedullary . syringomyelia
Study Design: from July 2003 till July 2008 A prospective study of 120 patients who underwent unilateral or bilateral pedicle screw fixation in cairo university hospitals.
Objectives: To determine whether unilateral pedicle screw fixation is comparable with bilateral fixation in one segment lumbar spinal fusion.
Methods: 120 patients were assigned to either unilateral (60) or bilateral (60) pedicle screw instrumentation groups. Several types of pedicle screw system (Moss Miami, DePuy, sofamordanek, AcroMed, technosite,) were used. Operating time, blood loss, duration of hospital stay, clinical outcomes, fusion rates, complication rates, and medical expenses were studied .
Results: There were no significant differences between the two groups in blood loss, clinically satisfactory results, fusion rate, and complication rate. There were significant differences in duration of operating time, duration of hospital stay, and medical expenses. The kinds of instrumentation did not affect the fusion rate or clinical outcomes.
Conclusions: Unilateral pedicle screw fixation was as effective as bilateral pedicle screw fixation in lumbar spinal fusion in single level independent of pedicle screw systems. Based on the results of this study, unilateral fixation could be used in one level lumbar spinal fusion.
Key words: bilateral, pedicle screw fixation, unilateral, spondylolisthesis
Objective: Aim of this work is to asses and evaluates frontolateral craniotomy via a superciliary skin incision performed on 26 patients with various anterior skull base and sellar tumours regarding its advantages and disadvantages.
Methods: The frontolateral keyhole craniotomy is a modification of the generally used pterional approach. This study was applied on 26 patients, ten patients (six women and four men) with suprasellar meningiomas. six patients (three males and three females) with craniopharyngioma. eight patients (three males and five female) with huge pituitary adenoma and two patient with olfactory groove menengioma. The operations were carried out through an approximately 2.5- 3.5 cm frontolateral craniotomy via a superciliary skin incision.
Results: Despite the small size of the craniotomy, it allows enough room for intracranial manipulation with maximal protection of the brain and other intracranial structures. The presented series of patients have mild craniotomy-related complications. With excellent cosmotic results.
Conclusion: In our experience, the frontolateral keyhole craniotomy, together with development of the modern neuroanesthesia, cerebrospinal fluid drainage, and microsurgical techniques, is a safe approach for an experienced neurosurgeon to be used in the treatment of tumors of the anterior cranial fossa and sellar regions.
Key words: Frontolateral - Keyhole craniotomy - Superciliary - Anterior skull base
Introduction: This is a retrospective study of 16 patients with grossly cystic craniopharyngiomas (primary cystic or recurrent cystic craniopharyngiomas) whom were treated surgically by implantation of Ommaya reservoir system (ORS) in department of neurosurgery, Cairo university hospitals and Nasser institute hospital.
Objective: The objective of this study was to evaluate the role of percutaneous drainage using the Ommaya reservoir system as a therapeutic option in the management of grossly cystic craniopharyngiomas.
Patients and methods: Between January 2004 and December 2007, 16 patients were referred for insertion of Ommaya reservoir system for drainage of their cystic craniopharyngiomas. All procedures were performed at Neurosurgery Department, Cairo University hospitals and Nasser Institute Patients were selected on the basis of having their CT scan and MRI disclosure of: 1- Unilocular cystic craniopharyngioma, either primary or recurrent. 2- The craniocaudal dimension of the cyst was at least 3cm. 3- The cyst wall was not too thick or calcified to be easily punctured. There were 9 males and 7 females vary in age from 7 to 52 years.
Results: The results with regard to cyst response after Ommaya reservoir system placement with radiosurgery or radiotherapy. Three patient (18.75%) the cyst disappear completely, Nine patients (56.25%) the cyst decrease in size and four patient (25%) need infrequent aspiration.
Conclusion: Treatment of grossly cystic craniopharyngiomas (primary or recurrent) by percutaneous aspiration via Ommaya reservoir system can be considered as a suitable treatment option. The drainage procedure is expected to improve the results of subsequent treatment either using radiotherapy or radiosurgery by reducing the volume of the target and overcoming problems related to the fluid portion of the tumor on which the ionizing radiation has no effect.
Keywords: Craniopharyngioma, Ommaya reservoir, Therapeutic option.
Objectives: to evaluate prospectively the radiological and clinical outcome of anterior cervical discectomy followed by implantation of an empty cage of any type in the treatment of patients with cervical disc problems
Methods: From January 2006 till December 2008, 125 patients (80men, 45 women, mean age 45 years) with cervical disc diseases due to cervical disc herniation and osteophyte were treated by anterior cervical discectomy followed by implantation of an empty cage. On lateral flexion-extension radiographs segmental stability at a mean follow up of 17 months (range 3-34 months) was demonstrated in all 125 patients, Self-scored neck pain based on a visual analog scale (1, minimum; 10, maximum) changed from a preoperative average of 7 to an average of 2 at follow up; radicular pain was reduced from 6 to 2.1 postoperatively
Conclusions: Implantation of an empty cervical cages in the treatment of cervical disc herniation avoids donor site morbidity associated with autologous bone grafting as well as the use of any supplementary material inside the cage. Restoration or maintenance of intervertebral height and thus segmental lordosis and a very high rate of segmental stability and fusion are achieved using this technique.
Key Words: Anterior cervical discectomy, interbody cage, empty cage
Study design: Retrospective.
Objective: To report on the functional outcome, clinical results and complications of Neuromuscular Scoliosis (NMS) due to poliomyelitis in ambulatory patients treated with third generation instrumented spinal fusion (3G-ISF) without extension to the pelvis or the sacrum. Background Data:
Posterior instrumentation with extension to the pelvis has long been considered the gold standard for progressive NMS (Neuromuscular scoliosis), despite major complications affecting 10 to 60% of treated patients. Comparison with the results of newer generation in NMS is lacking. There has been no studies reporting the results of spinal fusion for scoliosis in ambulatory patients with poliomyelitis. It has always been of concern if gait is affected following surgery in these patient population.
Methods: NMS patients due to poliomyelitis treated consecutively by the authors from 2001 to 2006 by 3G-1SF and minimum 18 months follow-up were reviewed clinically and radiographically. All patients were assessed pre and 1 year postoperatively by the a specialized paediatrician for proper independent assessment of the clinical results, affection of ambulation and patient satisfaction
Results: 18 (5 females, 13 males) patients were included. Mean age at surgery was 14 (range, 11-17) years. Mean follow-up was 25 (range, 19-38) months. All had staged (1 week apart) anterior release and fusion followed by posterior instrumented fusion not including the pelvis nor the sacrum There were 10 patients fused to L4 and 8 to L5. Correction of coronal deformity averaged 61% Correction of pelvic obliquity averaged 45% Major complications affected only two patients. Follow-up questionnaires highlighted an overall improved quality of patients' life with no major affection regarding the degree of ambulation.
Conclusions: Over 2 years after surgery, segmental 3G-ISF provides lasting correction of spinal deformity and improved quality of life of patients having Scoliosis due to poliomyelitis, with a lower complication rate than previously reported. Spinal fusion for scoliosis due to poliomyelitis in ambulatory patients is effective and the results are satisfactory. The patient's gait was not affected and there was a high level of satisfaction following this type of surgery.
Keywords: neuromuscular scoliosis, spinal fusion, third generation instrumentation, poliomyelitis
Objectives: The aim of this study was to asses trigeminal neuralgia due to non vascular causes regarding the characteristic features of pain and its offending causes, and also to asses the response of pain relief after microsurgical release of trigeminal nerve.
Patients and Methods: Between the years 2000 and 2008, twelve patients presenting with trigeminal neuralgia (TN) of non-vascular origin underwent surgery at Kasr El Eini University Hospitals. The patients were 7 females and 5 males. The age of the patients ranged from 31 to 64 years. The mean age was 42 years. All the patients suffered from trigeminal neuralgia. The offending causes were four epidermoid cysts, four meningiomas, two acoustic neuromas and two trigeminal neuromas. All the patients improved after surgery.
Conclusion: Trigeminal neuralgia due to non vascular causes has special characters as it is usually associated with some features such as dysesthesia, hypothesia, constant background pain, presence of associated neurological abnormalities and exhibits no response to medical treatment. Perfect microsurgical decompression of trigeminal nerve gives excellent results regarding pain relief.
Objective: The purpose of this study is to analyze a subgroup of patients harboring anterior lateral intraventricular tumours operated via limited anterior transcallosal approach, as regard clinical presentation, neuropathology postoperative results and complications.
Method: Twelve patients of anterior lateral intraventricular tumours were included in this study. They were 7 males and 5 females with age ranging from 7 to 42 years, and the median age was 21 years. The most common presenting complaint was headache (42%) followed by cognitive dysfunction (17%) and gait disturbance (17%) while visual deficits and focal fits were the least. Preoperative clinical and neuroradiological evaluation was performed for every patient including MRI and MRA or CT angiography to evaluate parasagittal venous drainage. The surgical technique was discussed and all patients were operated via the limited anterior transcallosal approach with a callosotomy 2 cm or less. Total tumour excision was accomplished in 10 patients (83%) and subtotal in the remainder. We had 4 cases of ependymoma (42%), 3 cases of Astrocytoma G II (25%), 3 cases of central neurocytoma, (25%) and one case of juvenile pilocytic astrocytoma, (8%) and one case of choroid plexus papilloma (8%). Regarding complications we had 2 cases of residual hydrocephalus who required ventriculoperitoneal shunting, (17%), one case of focal seizure due to a small venous infarction (8%), one case of subdural hygroma (8%) required burr hole drainage, and one case of transient mutism (8%). There were no disconnection syndromes, no further neurological deficits or any mortality.
Conclusions: The limited transcallosal approach is an ideal route to reach tumours of the anterior lateral ventricle with very limited morbidity and mortality in comparison with other approaches, provided that good preoperative planning and meticulous operative technique are performed.
Objectives: The preoperative estimation of serum levels of protein S100 B in patients with traumatic brain injury (TBI) as a prognostic marker for their outcome is evaluated in this study, considering TBI as any blow to the head causing a clinical diagnosis of head injury to be made, even if insufficient to cause definite loss of consciousness.
Patients & Methods: The study included 40 patients with TBI of varied severity and 10 volunteers as a control group. The initial severity of the injury was assessed using the Glasgow coma score (GCS), and neurological assessment were performed at the emergency department. Cranial CT scans without contrast enhancement were performed soon after admission. All patients received measures to decrease intracranial pressure and phyntoin for posttraumatic seizures and as a neuroprotector. Operative procedures were conducted according to the type of post-traumatic lesion. Follow-up was conducted monthly and the final outcome at six months was assessed using the Expanded Disability Status Scale (EDSS) and the final outcome was considered unfavorable if the patient had EDSS?5.
Results: The study comprised 40 patients with a mean age of 42.7±8.8 years; 17 patients (42.5%) had loss of consciousness at the scene of the accident; 9 patients (22.5%) arrived unconscious and 26 patients (65%) had posttraumatic amnesia. Twenty-one patients (52.5%) had isolated TBI, while 19 patients (47.5%) had TBI associated with multiple trauma. Mean initial GCS score was 11.1±3 and normal CT was reported in 14 patients (35%). Throughout ICU stay 15 patients died for a mortality rate of 37.5% and 9 of the survivors (36%) had unfavorable outcome with EDSS?5. Serum S100B levels were significantly higher in patients compared to control levels, in non-survivors compared to survivors and in patients with unfavorable compared to favorable outcome. There was a negative significant correlation between serum S100B levels and both GCS and survival, while survival showed a positive significant correlation with GCS. Moreover, serum S100B levels showed negative significant correlation with clinically evaluated neurological outcome. Using ROC curve, serum S100 B levels were found to be the most specific predictor of mortality (AUC=0.960), followed by time lag between trauma affliction and sampling (AUC=0.532) and was the most specific predictor of unfavorable neurological outcome (AUC=0.844) followed by age (AUC=0.622). ROC curve analysis defined serum level of S100B at cutoff point of ?0.52 (AUC=0.697) as the most appropriate cutoff point for identification of patients with predicted survival and favorable neurological outcome with specificity rate of 55.6% and 66.7%, respectively and accuracy rate of 70% and 80%, respectively.
Conclusion: It could be concluded that preoperative estimation of serum S100B protein in patients with TBI could be used as a prognostic predictor for postoperative survival and neurological outcome. Serum levels of ?0.52 µg/L indicated bad prognosis.
| Results 1-14 |
| Note: The previous issues are being prepared to be published soon |