bluuebunny/crossref_metadata_2025 huggingface dataset:
Peripheral nerve surgery and neurosurgeons: results of a national survey of practice patterns and attitudes
Authors: Maniker Allen , Passannante Marian
Published: January 2008

Object

The goal of this study was to determine current practice patterns and attitudes of neurosurgeons toward peripheral nerve surgery.

Methods

A 13-question survey was mailed to all active members of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. Collected responses were entered into a database and were analyzed using statistical software.

Conclusions

Of 3800 surveys mailed there were 1728 responses for a 45% response rate. Analysis of the data revealed that respondents had a greater comfort level with simple peripheral nerve procedures, such as carpal tunnel release, and a lack of comfort with more complex peripheral nerve procedures, such as brachial plexus exploration. The majority of simple cases were treated by the surveyed neurosurgeons, whereas the majority of complex cases were referred to other surgeons, primarily to other neurosurgeons. The type of medical practice (academic, group, or solo) and the location of the practice (major city, small city, suburban setting, or rural area) showed a statistically significant correlation to simple case referral patterns, whereas the length of time since the respondent underwent training did not. Practice type and location, and years since training showed a statistically significant correlation to complex case referral patterns. Only 48.7% of the respondents believed that they had been given sufficient exposure to peripheral nerve surgery during residency training. The overwhelming majority (97.2%) of respondents favored keeping peripheral nerve surgery as part of the neurosurgical curriculum.
Nerve transfers to the biceps and brachialis branches to improve elbow flexion strength after brachial plexus injuries
Authors: Tung Thomas H. , Novak Christine B. , Mackinnon Susan E.
Published: January 2008

Object

In this study the authors evaluated the outcome in patients with brachial plexus injuries who underwent nerve transfers to the biceps and the brachialis branches of the musculocutaneous nerve.

Methods

The charts of eight patients who underwent an ulnar nerve fascicle transfer to the biceps branch of the musculocutaneous nerve and a separate transfer to the brachialis branch were retrospectively reviewed. Outcome was assessed using the Medical Research Council (MRC) grade to classify elbow flexion strength in conjunction with electromyography (EMG).

The mean patient age was 26.4 years (range 16–45 years) and the mean time from injury to surgery was 3.8 months (range 2.5–7.5 months). Recovery of elbow flexion was MRC Grade 4 in five patients, and Grade 4+in three. Reinnervation of both the biceps and brachialis muscles was confirmed on EMG studies. Ulnar nerve function was not downgraded in any patient.

Conclusions

The use of nerve transfers to reinnervate the biceps and brachialis muscle provides excellent elbow flexion strength in patients with brachial plexus nerve injuries.
Pathophysiology of peripheral nerve injury: a brief review
Authors: Burnett Mark G. , Zager Eric L.
Published: January 2008

Clinicians caring for patients with brachial plexus and other nerve injuries must possess a clear understanding of the peripheral nervous system's response to trauma. In this article, the authors briefly review peripheral nerve injury (PNI) types, discuss the common injury classification schemes, and describe the dynamic processes of degeneration and reinnervation that characterize the PNI response.
Upper thoracic spinal cord herniation after traumatic nerve root avulsion
Authors: DaSilva Victor R. , Al-Gahtany Mubarak , Midha Rajiv , Sarma Dipanka , Cooper Perry
Published: January 2008

✓ Transdural herniation of the spinal cord, a rare but well-documented entity, has been reported sporadically for more than 25 years as a possible cause for various neurological signs and symptoms ranging from isolated sensory or motor findings to myelopathy and Brown–Séquard syndrome. The authors report, to the best of their knowledge, the first case of upper thoracic spinal cord herniation occurring after traumatic nerve root avulsion.
Mechanisms of injury in operative brachial plexus lesions
Authors: Kim Daniel H. , Murovic Judith A. , Tiel Robert L. , Kline David G.
Published: January 2008

Object

The authors focus on injury mechanisms involved in 1019 operative brachial plexus injuries (BPIs) managed between 1968 and 1998 at Louisiana State University Health Sciences Center (LSUHSC).

Methods

Data regarding these mechanisms of injury were obtained via retrospective chart reviews of patients who had undergone operations at LSUHSC.

Five main mechanisms of injury to the brachial plexus occurred in the series. These included 509 stretch/contusion injuries (49%) with four patterns of presentation in 366 patients: 208 C5–T1 nerve injuries; 75 C5–7, 55 C5–6 injuries; and 28 involving the C8–T1 or C7–T1 nerves. Stretch/contusion injury was followed in frequency by gunshot wound (GSW), resulting in 118 injuries (12%). Most of the 293 involved plexus elements had some gross continuity when surgically exposed. Seventy-one lacerations involved the brachial plexus (7%), including 83 sharp lacerations caused by knives or glass; 61 blunt transections due to automobile metal, fan, and motor blades, chain saws, or animal bites.

Nontraumatic BPIs included 160 cases of thoracic outlet syndrome or 16% of the total of 1019 BPIs. There were 161 tumors (16%) of neural sheath origin including 55 solitary neurofibromas (34%), 32 neurofibromas associated with von Recklinghausen disease (20%), 54 schwannomas (34%), and 20 malignant nerve sheath tumors (20%) removed. Obstetrical BPI was not included in the original series; however, the current literature is reviewed in this paper.

Conclusions

The conclusion of this study is that the brachial plexus can be injured by multiple mechanisms of which stretch/contusion injury is the most frequently encountered, followed by GSWs.
Penetrating injuries due to gunshot wounds involving the brachial plexus
Authors: Kim Daniel H. , Murovic Judith A. , Tiel Robert L. , Kline David G.
Published: January 2008

The authors review 118 operative brachial plexus gunshot wounds (GSWs), causing 293 element injuries that were managed over a 30-year period at Louisiana State University Health Sciences Center (LSUHSC). Retrospective chart reviews were performed. Using the LSUHSC grading system for motor sensory function, each element's grades were combined and averaged.

Most of the 293 injured elements were found to have gross continuity at operation and of 202 elements with complete neurological loss, only 16 (8%) exhibited total disruption. Of 293 injuries, 128 elements with complete or incomplete loss were not only in continuity when explored but also had positive intraoperative nerve action potentials (NAPs). After neurolysis, 120 of 128 elements in continuity (94%) improved to greater than or equal to Grade 3 function. Elements not regenerating early usually required repair. One hundred fifty-six of 202 completely or incompletely injured elements (77%) required resection and suture or graft repair based on intraoperative NAPs. Neurolysis achieved greater than or equal to Grade 3 results in 42 (91%) of 46 elements with complete loss. Suture repair resulted in good outcomes in 14 (67%) of 21 and in 73 (54%) of 135 undergoing graft repairs (1 to 3.5 cm length) and presenting with complete loss.

Of 91 incomplete elements, intraoperative NAPs were positive in 82 (90%) and 78 of 82 had good results. Nine had negative NAPs and six elements required suture repair. Three required grafts with results of greater than or equal to Grade 3 in five (83%) of six and two (67%) of three, respectively.

Based on 118 patient results with 293 injured elements, guidelines for the management of GSWs were established as described in this paper.
Reinnervation of the biceps in C5–7 brachial plexus avulsion injuries: results after distal bypass surgery
Authors: Ferraresi Stefano , Garozzo Debora , Buffatti Paolo
Published: January 2008

Object

The authors report various techniques, and their results, after performing median and ulnar nerve transfers to reanimate the biceps muscle in C5–7 avulsion-related brachial plexus injuries (BPIs).

Methods

Forty-three adult patients with BPIs of the upper-middle plexus underwent reinnervation of the biceps muscle; neurotization of the musculocutaneous nerve was performed using fascicles from the ulnar nerve (39 cases) and the median nerve (four cases). The different techniques included sectioning, rerouting, and direct suturing of the entire musculocutaneous nerve (35 cases); direct reinnervation of the motor branches of the musculocutaneous nerve (three cases); and reinnervation using small grafts to the motor fascicles that enter the biceps muscle (five cases).

Elbow flexion recovery ranged from M2 to M4+, according to the patient's age and the level of integrity of the hand. No surgery-related failure occurred. No significant difference in outcome was related to any of the technical variants. In patients younger than age 45 years and exhibiting a normal hand function a score of M4 or better was always achieved. On average, reinnervation occurred 6 months after surgery. There was no clinical evidence of donor nerve dysfunction.

Conclusions

When accurate selection criteria are met, the results after this type of neurotization have proved excellent.
Cauda equina syndrome caused by primary and metastatic neoplasms
Authors: Bagley Carlos A. , Gokaslan Ziya L.
Published: January 2008

Cauda equina syndrome (CES) is defined as the constellation of symptoms that includes low-back pain, sciatica, saddle anesthesia, decreased rectal tone and perineal reflexes, bowel and bladder dysfunction, and variable amounts of lower-extremity weakness. There are several causes of this syndrome including trauma, central disc protrusion, hemorrhage, and neoplastic invasion. In this manuscript the authors reviewed CES in the setting of both primary and secondary neoplasms. They examined the various primary tumor types in this region as well as those representative of metastatic spread. Both surgical and nonsurgical management in this setting were studied.
Cauda equina syndrome as a postoperative complication of lumbar spine surgery
Authors: Jensen Randy L.
Published: January 2008

Object

The term “cauda equina syndrome” (CES) has been used to describe the signs and symptoms in patients with compressive neuropathy of multiple lumbar and sacral roots. This syndrome is well known as an indication for surgical intervention in treating lumbar spine disease, but relatively unknown as a postoperative complication following surgery for disease. In this study the author describes two cases of CES that occurred following uneventful lumbar spine procedures—one microdiscectomy and one decompressive laminectomy.

Methods

Preoperative, operative, and postoperative management is discussed and the relevant literature reviewed. One patient suffered perineal numbness and bowel and bladder difficulty following a decompressive laminectomy. Postoperative imaging studies were negative for residual lesion and the treatment goal pursued was partial long-term resolution of symptoms. The second patient had progressive numbness and weakness in the lower extremities. Results of urgent postoperative magnetic resonance imaging studies were inconclusive and repeated exploration was performed within hours of the initial procedure. The patient made a full recovery, although the intraoperative findings did not reveal a clear cause of the patient's symptoms.

Conclusions

Postoperative symptoms of partial or complete CES represent a medical emergency, especially if they are progressive. It is necessary to perform urgent postoperative imaging in patients, but the results are not always helpful. Surgical exploration is warranted if a mass lesion is demonstrated on imaging studies or if symptoms progress and the disease origin is not clear based on available information.
Deep brain stimulation for hyperkinetic disorders
Authors: Montgomery Erwin B.
Published: January 2008

Deep brain stimulation (DBS) has a record of safety and efficacy for an expanding range of indications. Recently, the Food and Drug Administration provided approval through a Humanitarian Device Exemption for DBS of the globus pallidus internus and subthalamic nucleus for the treatment of dystonia. There is increasing clinical experience demonstrating that DBS is also effective for other hyperkinetic disorders such as chorea from a variety of causes. The selection criteria, intraoperative targeting, and the postoperative management of DBS for hyperkinetic disorders are discussed.
Immediate and sustained relief of levodopa-induced dyskinesias after dorsal relocation of a deep brain stimulation lead
Authors: Alterman Ron L. , Shils Jay L. , Gudesblatt Mark , Tagliati Michele
Published: January 2008

The authors demonstrate that high-frequency electrical stimulation dorsal to the subthalamic nucleus (STN) can directly suppress levodopa-induced dyskinesias. This 63-year-old woman with idiopathic Parkinson disease underwent surgery for placement of bilateral subthalamic deep brain stimulation (DBS) electrodes to control progressive rigidity, motor fluctuations, and levodopa-induced dyskinesias. The model 3389 DBS leads were implanted with microelectrode guidance. Magnetic resonance imaging confirmed proper placement of the leads. Postoperatively the patient exhibited improvement in all of her parkinsonian symptoms; however, her right leg dyskinesias had not improved. Based on their previous experiences treating levodopa-induced dyskinesias with subthalamic stimulation through the more dorsally located contacts of the model 3387 lead, the authors withdrew the implanted 3389 lead 3 mm. Following relocation of the lead they were able to suppress the right leg dyskinesias by using the most dorsal contacts. The patient's dopaminergic medication intake increased slightly. These findings indicate that electrical stimulation dorsal to the STN can directly suppress levodopa-induced dyskinesias independent of dopaminergic medication changes. The 3389 lead may provide inadequate coverage of the subthalamic region for some patients.
Reduction in leg pain and lower-extremity weakness with Oxiplex/SP Gel for 1 year after laminectomy, laminotomy, and discectomy
Authors: Kim Kee D. , Wang Jeffrey C. , Robertson Daniel P. , Brodke Darrel S. , BenDebba Mohammed , Block Kathleen M. , diZerega Gere S.
Published: January 2008

Object

Although good surgical technique is effective in reducing postoperative epidural fibrosis, compression or tethering of the nerve root may cause recurrent radicular pain and physical impairment. The implantation of a bioresorbable gel on the dura may further decrease the amount of scar formation after surgery and thus improve the patient's ability to perform activities of daily living (ADL). This study is a 12-month evaluation of the safety and effectiveness of Oxiplex/SP Gel (FzioMed, Inc., San Luis Obispo, CA) in the reduction of pain and radiculopathy after lumbar discectomy.

Methods

A pilot randomized single-blind multicenter clinical trial was conducted to evaluate the performance of Oxiplex/SP Gel in patients who underwent surgery for unilateral herniation of the lumbar disc at L4–5 or L5–S1. Eighteen patients with severe leg pain and lower-extremity weakness (11 women and seven men) were randomly assigned intraoperatively to receive the gel at the conclusion of surgery (treatment group) or to undergo surgery alone (control group). Self-assessment questionnaires (Lumbar Spine Outcomes Questionnaire) to assess pain, symptoms, and ADL were completed preoperatively and at scheduled postoperative intervals (30 days, 90 days, 6 months, and 12 months).

The authors examined the spine and lower extremities of patients scheduled for discectomy to assess neurological function and pain. Treated patients received sufficient Oxiplex/SP Gel (1–3 ml) to coat the nerve root and fill the epidural space. Postoperative clinical evaluations were performed at 30 and 90 days. Patients completed the self-assessment questionnaires at baseline and were contacted by telephone or mail for the completion of the postoperative self-assessment questionnaires.

Surgical procedures were well tolerated; no device-related adverse events and no clinically significant laboratory results were reported. The 11 patients with severe leg pain and lower-extremity weakness who were treated with Oxiplex/SP Gel had a reduction in those symptoms at 30 days, 90 days, 6 months, and 12 months after discectomy, compared with the seven control patients who underwent surgery only.

Conclusions

Oxiplex/SP Gel was easy to use and safe in patients who underwent unilateral discectomy. A greater benefit in clinical outcome measures was seen over the 12-month follow-up period in gel-treated patients.
Glomus jugulare tumors: historical overview of the management of this disease
Authors: Michael L. Madison , Robertson Jon H.
Published: January 2008

The treatment of glomus jugulare tumors presents the surgeon with a significant management problem. Because the neoplasm originates in the region of the jugular bulb, it frequently involves the lower cranial nerves, with occasional extension into the posterior fossa. Despite extensive work on the development of surgical and radiation treatment strategies, considerable controversy still exists regarding the optimal management of these lesions. A historical review of the development of management options for glomus jugulare tumors is presented in an effort to offer a foundation for understanding their contemporary treatment.
The basic science of glomus jugulare tumors
Authors: Heth Jason
Published: January 2008

Glomus tumors are a fascinating group of lesions. It is a challenge for neurosurgeons and otolaryngologists to resect them completely with minimal morbidity. Laboratory researchers have discovered extremely interesting genetic and molecular biology factors involved in the development and growth of glomus tumors. In this article the author reviews the genetics, protein mutations, angiogenesis and apoptosis associated with tumor formation, and the secretion of vasoactive substances is discussed as well. It is hoped that with further research less invasive measures may be developed to treat these tumors.
Comparison of radiosurgery and conventional surgery for the treatment of glomus jugulare tumors
Authors: Gottfried Oren N. , Liu James K. , Couldwell William T.
Published: January 2008

Object

The optimal management of glomus jugulare tumors remains controversial. Available treatments were once associated with poor outcomes and significant complication rates. Advances in skull base surgery and the delivery of radiation therapy by stereotactic radiosurgery have improved the results obtained using these treatment options. The authors summarize and compare the contemporary outcomes and complications for these therapies.

Methods

Papers published between 1994 and 2004 that detailed the use of radiosurgery or surgery to treat glomus jugulare tumors were reviewed. Eight radiosurgery series including 142 patients and seven surgical studies including 374 patients were evaluated for neurological outcome, change in tumor size (radiosurgery) or percent of total resection (surgery), recurrences, tumor control, need for further treatment, and complications.

The mean age at treatment for patients who underwent surgery and radiosurgery was 47.3 and 56.7 years, respectively. The mean follow-up duration was 49.2 and 39.4 months, respectively. The surgical control rate was 92.1%, with 88.2% of tumors totally resected in the initial surgery. A cerebrospinal fluid leak occurred in 8.3% of patients who underwent surgery and recurrences were found in 3.1%; the mortality rate was 1.3%. Among patients who underwent radiosurgery, tumors diminished in 36.5%, whereas 61.3% had no change in tumor size, and subjective or objective improvements occurred in 39%. Despite the presence of residual tumor in 100% of radiosurgically treated patients, recurrences were found in only 2.1%, the morbidity rate was 8.5%, and there were no deaths.

Conclusions

Death and recurrences after these treatments are infrequent, and therefore both treatments are considered to be safe and efficacious. Although surgery is associated with higher morbidity rates, it immediately and totally eliminates the tumor. The radiosurgery results are very promising, although the incidence of late recurrence (after 10–20 years) is unknown.
Jugular foramen tumors: diagnosis and treatment
Authors: Ramina Ricardo , Maniglia Joao Jarney , Fernandes Yvens Barbosa , Paschoal Jorge Rizzato , Pfeilsticker Leopoldo Nizan , Neto Maurício Coelho , Borges Guilherme
Published: January 2008

Object

Jugular foramen tumors are rare skull base lesions that present diagnostic and complex management problems. The purpose of this study was to evaluate a series of patients with jugular foramen tumors who were surgically treated in the past 16 years, and to analyze the surgical technique, complications, and outcomes.

Methods

The authors retrospectively studied 102 patients with jugular foramen tumors treated between January 1987 and May 2004. All patients underwent surgery with a multidisciplinary method combining neurosurgical and ear, nose, and throat techniques. Preoperative embolization was performed for paragangliomas and other highly vascularized lesions. To avoid postoperative cerebrospinal fluid (CSF) leakage and to improve cosmetic results, the surgical defect was reconstructed with specially developed vascularized flaps (temporalis fascia, cervical fascia, sternocleidomastoid muscle, and temporalis muscle). A saphenous graft bypass was used in two patients with tumor infiltrating the internal carotid artery (ICA). Facial nerve reconstruction was performed with grafts of the great auricular nerve or with 12th/seventh cranial nerve anastomosis. Residual malignant and invasive tumors were irradiated after partial removal.

The most common tumor was paraganglioma (58 cases), followed by schwannomas (17 cases) and meningiomas (10 cases). Complete excision was possible in 45 patients (77.5%) with paragangliomas and in all patients with schwannomas. The most frequent and also the most dangerous surgical complication was lower cranial nerve deficit. This deficit occurred in 10 patients (10%), but it was transient in four cases. Postoperative facial and cochlear nerve paralysis occurred in eight patients (8%); spontaneous recovery occurred in three of them. In the remaining five patients the facial nerve was reconstructed using great auricular nerve grafts (three cases), sural nerve graft (one case), and hypoglossal/facial nerve anastomosis (one case). Four patients (4%) experienced postoperative CSF leakage, and four (4.2%) died after surgery. Two of them died of aspiration pneumonia complicated with septicemia. Of the remaining two, one died of pulmonary embolism and the other of cerebral hypoxia caused by a large cervical hematoma that led to tracheal deviation.

Conclusions

Paragangliomas are the most common tumors of the jugular foramen region. Surgical management of jugular foramen tumors is complex and difficult. Radical removal of benign jugular foramen tumors is the treatment of choice, may be curative, and is achieved with low mortality and morbidity rates. Larger lesions can be radically excised in one surgical procedure by using a multidisciplinary approach. Reconstruction of the skull base with vascularized myofascial flaps reduces postoperative CSF leaks. Postoperative lower cranial nerves deficits are the most dangerous complication.
Anatomy involved in the jugular foramen approach for jugulotympanic paraganglioma resection
Authors: Inserra Michelle M. , Pfister Markus , Jackler Robert K.
Published: January 2008

The goal in paraganglioma resection is to allow adequate exposure to remove the lesion while preserving cranial nerve function. Knowledge of the anatomy of the jugular foramen is crucial to this endeavor. In this report the authors describe a jugular foramen approach for the resection of glomus jugulare tumors in cases in which rerouting of the facial nerve can be avoided. This approach provides adequate exposure of the jugular bulb for many jugulotympanic paragangliomas without increased risk of injury to the facial nerve. In addition, special circumstances surrounding intracranial and carotid artery involvement are briefly discussed.
Surgical treatment of glomus jugulare tumors without rerouting of the facial nerve: an infralabyrinthine approach
Authors: Borba Luis A. B. , Ale-Bark Samir , London Charles
Published: January 2008

Object

Glomus jugulare tumors are benign lesions located in the jugular foramen that may or may not extend into the middle ear, petrous apex, and upper neck; these growths sometimes invade intradurally. The surgical management of these tumors is a challenge to neurosurgeons and skull base surgeons. Because of their abundant vascularity, deep location, complex anatomy, and difficult surgical approach, their treatment, has been a controversial issue for many years. Despite advancements in nonsurgical techniques, the only treatment with proven efficacy is radical surgical removal. The authors present a series of patients treated with radical removal, in which the feasibility of removing glomus jugulare tumors with low morbidity and a surgical approach limited to tumor removal are discussed. The extent of surgical exposure is tailored with emphasis placed on the routine anterior transposition of the facial nerve.

Methods

Between May 1997 and March 2004, 24 patients with glomus jugulare tumors were treated; 17 patients were women and seven were men. Their mean age at the time of diagnosis was 50 years (range 18–71 years). The most common symptom was hearing loss in 77%, followed by dysphagia and dysphonia in 55% of patients. In seven patients the clinical presentation was a facial palsy. Radical tumor removal was achieved in 23 patients. An anterior facial nerve transposition was not needed in any case. No surgery-related death was recorded in this series, although one patient died of a pulmonary embolism 70 days after the procedure. A one-stage procedure was performed in 23 patients and a two-stage procedure was used in the other patient. Cerebrospinal fluid leakage occurred in two patients. The lower cranial nerve function was worse in eight patients; however, only one had a new deficit. The facial nerve was preserved in all patients except one, in whom a large intradural tumor caused a temporary facial palsy. In the patients with pre-operative facial palsy, the tumor only compressed the nerve in three and it invaded the nerve in four. The nerve was decompressed in the cases with no invasion and a graft was placed in the others. The greater auricular nerve was used as a graft in three and the sural nerve was used in one. On follow-up review, the facial nerve function was House–Brackmann Grade 3 in three patients and Grade 2 in three. After 6 months of follow up with no improvement, one patient was referred for a facial muscle transfer.

Conclusions

The surgical technique must be tailored to each case. The authors believe that the standard surgical approach to jugular foramen tumors with anterior transposition of the facial nerve should be avoided, and that the extent of surgical exposure must be tailored to each case based on the extent of the tumor and the clinical symptoms. Lower morbidity rates and radical removal can be achieved with a good surgical plan.
Surgical treatment of dumbbell-shaped jugular foramen schwannomas
Authors: Kadri Paulo A. S. , Al-Mefty Ossama
Published: January 2008

Object

Schwannomas of the jugular foramen are rare, comprising between 2 and 4% of intracranial schwannomas. The authors retrospectively analyzed their surgical experience with schwannomas of the lower cranial nerves that presented with intra- and extracranial extensions through an enlarged jugular foramen. The transcondylar suprajugular approach was used without sacrificing the labyrinth or the integrity of the jugular bulb. In this report the clinical and radiological features are discussed and complications are analyzed.

Methods

This retrospective study includes six patients (three women and three men, mean age 31.6 years) with dumbbell-shaped jugular foramen schwannomas that were surgically treated by the senior author during a 5.5-year period. One patient had undergone previous surgery elsewhere. Glossopharyngeal and vagal nerve deficits were the most common signs (appearing in all patients), followed by hypoglossal and accessory nerve deficits (66.6%). Two or more signs or symptoms were present in every patient. Three tumors presented with cystic degeneration. In four patients the jugular bulb was not patent on neuroimaging studies. The suprajugular approach was used in five patients; the origin of the tumor from the 10th cranial nerve could be defined in three of them. All lesions were completely resected. No death or additional postoperative cranial nerve deficits occurred in this series. Aspiration pneumonia developed in one patient. Preoperative deficits of the ninth and 10th cranial nerves improved in one third of the patients and half recovered mobility of the tongue. No recurrence was discovered during the mean follow-up period of 32.8 months.

Conclusions

With careful, extensive preoperative evaluation and appropriate planning of the surgical approach, dumbbell-shaped jugular foramen schwannomas can be radically and safely resected without creating additional neurological deficits. Furthermore, recovery of function in the affected cranial nerves can be expected.
The future in the care of the cervical spine: interbody fusion and arthroplasty
Authors: Mummaneni Praveen V. , Haid Regis W.
Published: January 2008

✓ In the past 50 years tremendous advances have been made in the treatment of cervical disc disease with cervical fusion. Fusion rates have surpassed 95% after application of anterior cervical implants. Adjacent-segment degeneration, however, has plagued the long-term clinical success of cervical fusion.

Cervical arthroplasty has been introduced to maintain cervical motion and potentially avoid or minimize adjacent-segment degeneration. If cervical arthroplasty is successful, the long-term results of surgery for cervical disc disease may improve; however, there are associated drawbacks that must be overcome. Implant wear, fatigue, and failure have been reported in cases of large-joint arthroplasty, and research is underway to limit these problems in cervical arthroplasty.

In this article the authors trace the evolution of cervical fusion and the new technique of cervical arthroplasty. The nomenclature of cervical arthroplasty will also be introduced.
Cervical arthroplasty: material properties
Authors: Smith Harvey E. , Wimberley David W. , Vaccaro Alexander R.
Published: January 2008

Discectomy, decompression, and fusion are traditionally used to manage cervical disc disease accompanied by neural element compression that is refractory to conservative management. Concerns regarding stress at levels adjacent to fusion and possible adjacent-level degeneration as well as a desire to maintain a more normal biomechanical environment have led to investigation of cervical disc replacement as an alternative to fusion procedures. Cervical disc prostheses currently under investigation are constructed of predominantly metal-on-polyethylene or metal-on-metal bearing surfaces, and use roughened titanium surfaces and osteoconductive coatings to facilitate fixation. The unique anatomy and biomechanics of the cervical spine must be considered when extrapolating from the experience of appendicular arthroplasty and lumbar disc replacement.
Prophylaxis for deep venous thrombosis in neurosurgery: a review of the literature
Authors: Browd Samuel R. , Ragel Brian T. , Davis Gary E. , Scott Amy M. , Skalabrin Elaine J. , Couldwell William T.
Published: January 2008

The incidence of deep venous thrombosis (DVT) and subsequent pulmonary embolism (PE) in patients undergoing neurosurgery has been reported to be as high as 25%, with a mortality rate from PE between 9 and 50%. Even with the use of pneumatic compression devices, the incidence of DVT has been reported to be 32% in these patients, making prophylactic heparin therapy desirable. Both unfractionated and low-molecular-weight heparin have been shown to reduce the incidence of DVT consistently by 40 to 50% in neurosurgical patients. The baseline rate for major intracranial hemorrhage (ICH) following craniotomy has been reported to be between 1 and 3.9%, but after initiation of heparin therapy this rate has been found to be as high as 10.9%. Therefore, neurosurgeons must balance the risk of PE against the increased risk of postoperative ICH from prophylactic heparin for DVT. The authors review the literature on the incidence of DVT and PE in neurosurgical patients, focusing on the incidence of ICH related to the use of unfractionated and low-molecular-weight heparin in this patient population
Efficacy of mechanical prophylaxis for venous thromboembolism in patients with brain tumors
Authors: Auguste Kurtis I. , Quiñones-Hinojosa Alfredo , Berger Mitchel S.
Published: January 2008

Patients with brain tumors are at considerable risk for the formation of venous thromboemboli. One method of preventing these complications is mechanical prophylaxis in which an external pneumatic compression device and graduated elastic compression stockings are used. Evidence indicates that these devices prevent deep venous thrombosis (DVT) and pulmonary embolism (PE) by limiting venous stasis and increasing fibrinolytic activity at both the local and systemic levels. The authors present evidence for the occurrence of both mechanisms and discuss the use of mechanical compression in the setting of surgery for brain tumors. They also present data proving the efficacy of these devices in patients who undergo craniotomy with motor mapping for resection of glioma and in whom the contralateral leg receives no prophylaxis. Finally, they comment on the use of anticoagulation therapy both in addition to and in place of mechanical prophylaxis.
Postoperative Level 1 anticoagulation therapy and spinal surgery: practical guidelines for management
Authors: Barnes Bryan , Alexander Joseph T. , Branch Charles L.
Published: January 2008

Object

The authors conducted a review of the literature to establish reasonable practical guidelines for the management of complications in patients who have undergone recent spinal surgery and who require Level 1 anticoagulation therapy.

Methods

A MEDLINE (PubMed) literature search was performed using the key words “postoperative anticoagulation,” “spinal surgery,” and “postoperative epidural hematoma,” for articles published between 1990 and 2004. The search yielded 148 articles, which were then further screened for relevance and classified according to level-of-evidence guidelines established by the American Association of Neurological Surgeons/Congress of Neurological Surgeons joint committee for spinal cord injury. A total of 12 relevant articles were reviewed. There were no relevant articles meeting Class 1 standards of evidence, two met Class 2 evidence standards (one was a nonrandomized cohort study, the other was case-controlled), and the remaining 10 articles contained Class 3 evidence.

Conclusions

There are insufficient data to establish evidence-based guidelines for the use of Level 1 heparin or an equivalent anticoagulation protocol in patients who have recently undergone spinal surgery. Nevertheless, a search of the limited peer-reviewed literature on the subject indicates that there is an anecdotally high risk of complications in patients who have undergone spinal surgery and in whom a Level 1 or equivalent heparin protocol is administered. It therefore seems most prudent to arrange for placement of a vena cava filter in patients who have undergone spinal surgery and in whom a pulmonary embolus is found postoperatively. In patients who undergo spinal surgery and who require heparinization therapy for myocardial ischemia or infarction, the use of frequent neurological examinations in conjunction with anticoagulation therapy seems to be the only reasonable option.
Natural history and general management of unruptured intracranial aneurysms
Authors: Chen Peng Roc , Frerichs Kai , Spetzler Robert
Published: January 2008

After an aneurysmal subarachnoid hemorrhage, nearly half of the patients die and the half who survive suffer from irreversible cerebral damage. With increasing use of noninvasive neuroimaging techniques (for example, magnetic resonance and computerized tomography angiography), more unruptured cerebral aneurysms are found. To understand the prevalence of unruptured aneurysms in the general population, along with the risks of aneurysm formation, data on growth and rupture rates are crucial. The risk of rupture in aneurysms smaller than 10 mm is still not quite clear without a population-based prospective study. Nevertheless, a 0.5 to 2% annual risk may be a reasonable estimate. Growing aneurysms and those larger than 10 mm carry a higher rate of rupture. The management of an unruptured intracranial aneurysm should be based on a thorough understanding of the natural history of these lesions and careful evaluation of the morbidity and mortality levels associated with each treatment option.
Stent-assisted coil placement for unruptured cerebral aneurysms
Authors: Jabbour Pascal , Koebbe Christopher , Veznedaroglu Erol , Benitez Ronald P. , Rosenwasser Robert
Published: January 2008

Object

The treatment of wide-necked cerebral aneurysms represents a challenging problem for neurosurgeons. The recent development of stents has provided clinicians with the ability to treat these aneurysms while keeping the parent vessel patent. The long-term occlusion rate of aneurysms treated with stent-assisted coil placement has yet to be investigated. The authors report the use of a new intracranial stent—the Neuroform microstent—in the treatment of unruptured wide-necked cerebral aneurysms.

Methods

Thirty-two patients harboring unruptured wide-necked intracranial aneurysms underwent a stent-assisted coil placement procedure. Patients were pretreated with antiplatelet agents, and a stent was positioned across the neck of the aneurysm. The next step was the insertion of coils into the aneurysm cavity. Patients received anticoagulation therapy for 24 hours after the procedure.

All 32 patients with unruptured wide-necked cerebral aneurysms were suitable candidates for this procedure. Occlusion of at least 90% of the aneurysm was achieved in 24 patients (75%) and 0% occlusion was observed in five patients (15%). Two patients experienced thromboembolic events, one of which was directly related to the stent. The overall complication rate was 6.3%.

Conclusions

Intracranial stents will be used more frequently in the new era of endovascular management of wide-necked cerebral aneurysms. With some technical improvements and more data on long-term occlusion rates, this new modality should improve the occlusion of wide-necked cerebral aneurysms while protecting the parent vessel.
Update on the management of unruptured intracranial aneurysms
Authors: Zipfel Gregory J. , Dacey Ralph G.
Published: January 2008

Over the past decade, several factors have led to a dramatic change in the manner in which patients with unruptured intracranial aneurysms are diagnosed and treated. These factors include the increased use of noninvasive imaging modalities for the diagnosis of intracranial aneurysms, publication of new natural history data detailing the hemorrhage risks associated with unruptured intracranial aneurysms, and the broad application of endovascular therapy for their treatment. With these new technologies and new natural history data has come considerable uncertainty about the optimal treatment strategy for patients with unruptured intracranial aneurysms. In this light, it seems prudent to review periodically and examine critically all recent data pertaining to the natural history and treatment of unruptured intracranial aneurysms, in an effort to provide a scientific update on which management recommendations can be based. This review article represents the authors' attempt at such an update, and it is their hope that members of the community of neurovascular surgeons might find this information helpful during their continuing efforts to provide optimal care for their patients with unruptured intracranial aneurysms.
Natural history of unruptured intracranial aneurysms
Authors: Ecker Robert D. , Hopkins L. Nelson
Published: January 2008

Since the publication of the retrospective part of the International Study of Unruptured Intracranial Aneurysms (ISUIA) in 1998, there has been a significant focus in the neurosurgical literature on the natural history of these lesions. The prospective data from the second part of the ISUIA, which was published in 2003, provided further evidence that small, asymptomatic intracranial aneurysms may have a more benign course than previously believed. With the data from the ISUIA as a reference point, in this paper the authors strive to provide a source of practical clinical data to aid cerebrovascular physicians in the initial decision to treat or observe a patient with a small, asymptomatic intracranial aneurysm. The issues covered will include previous rupture, symptoms other than rupture, aneurysm size, site, and aspect ratio. It is the authors' goal to provide a useful practical framework on the relevant clinical issues as an aid to practitioners treating patients who present with intracranial aneurysms.
Unruptured intracranial aneurysms: natural history and management decisions
Authors: da Costa Leodante B. , Gunnarsson Thorsteinn , Wallace M. Christopher
Published: January 2008

Aneurysmal subarachnoid hemorrhage (SAH) carries a grim prognosis, with high mortality and morbidity rates. The mortality rate in the first 30 days postrupture is estimated to be in the range of 40 to 50%, and almost half of the survivors will be left with a neurological deficit. Unlike patients with aneurysmal SAH, those with unruptured intracranial aneurysms usually experience no neurological deficit, and their treatment is prophylactic, aiming to reduce the risk of future bleeding and its consequences. The risk of rupture therefore assumes special importance when making decisions regarding which patient or aneurysm to treat.

In previous reports the risk of bleeding for unruptured aneurysms has been stated as approximately 2% per year. The retrospective part of the International Study of Unruptured Intracranial Aneurysms (ISUIA) reported very low annual bleeding rates (0.05–1%) and high surgical morbidity and mortality rates (8–18%), prompting discussion in which the benefits of prophylactic treatment in the majority of these lesions were questioned. Prospective data from the second part of the ISUIA recently included rupture rates ranging from 0 to 10% per year. The aim of this paper was to review the evidence that is currently available for neurosurgeons to use when making decisions regarding patients who would benefit from treatment of an unruptured intracranial aneurysm.
Update on genetic evidence for rupture-prone compared with rupture-resistant intracranial saccular aneurysms
Authors: Khurana Vini G. , Meissner Irene , Meyer Fredric B.
Published: January 2008

Object

Anecdotal evidence exists for at least two subpopulations of intracranial saccular aneurysms; those that form rapidly and rupture when small and those that enlarge slowly and are particularly prone to rupture when they are 10 mm or more in diameter. The goal in this study was to determine if there was genetic evidence to support the classification of intracranial saccular aneurysms as “rupture-prone” or “rupture-resistant” lesions.

Methods

The authors prospectively obtained and analyzed clinical and genetic data in a cohort of 197 individuals composed of 58 patients with ruptured intracranial saccular aneurysms, 49 with unruptured aneurysms, and 90 healthy community volunteers. Based on recent studies supporting an increasingly relevant role for the critical vasomodulatory protein endothelial nitric oxide synthase (eNOS) in aneurysm pathobiology, the authors assayed blood from all 197 participants to determine and compare their eNOS genotypes.

The eNOS gene intron 4 27–base pair variable-number tandem-repeat polymorphism was significantly overrepre-sented in persons with ruptured intracranial saccular aneurysms compared with community volunteers (p <0.002). When comparing eNOS genotypes among patients with ruptured or unruptured aneurysms, an approximately 10-fold increase in the odds of presenting with brain aneurysm rupture was found among individuals with multiple variant eNOS alleles (p = 0.004).

Conclusions

Uniquely, the authors have identified a set of eNOS gene variations whose presence indicates patients with intracranial saccular aneurysms that are more prone to rupture. The authors conclude that if these findings are reproducible in the setting of a large multicenter study, then in addition to known anatomical factors, a rapid and cost-effective genetic screening tool will become available to clinicians as an aid to predicting rupture risks in patients presenting with unruptured intracranial aneurysms.
Estimating the annual rate of de novo multiple aneurysms: three statistical approaches
Authors: Cheong James Ju Yong , Ghinea Narcyz , van Gelder James M.
Published: January 2008

Object

Individuals with unruptured intracranial aneurysms experience a higher rate of rupture if their history includes another aneurysm that has previously bled. The authors used systematic review and metaregression to estimate the annual rate of development of second de novo aneurysms after subarachnoid hemorrhage.

Methods

This investigation included studies in which more than 300 patients with intracranial aneurysms were described, and in which the age of the patients and the proportion with multiple aneurysms were documented. Studies describing delayed follow-up angiography that was performed after treatment of aneurysms were also reviewed.

Twenty studies were included in a between-study analysis. The univariate odds ratio (OR) for multiple intracranial aneurysms per year of age was 1.085 (95% confidence interval [CI] 1.015–1.165); this value was calculated using a hierarchical model for between-study heterogeneity. Five studies were included that provided age stratification. The estimated OR for multiple intracranial aneurysms per year was 1.011 (95% CI 1.005–1.018). Four follow-up studies were available.

Conclusions

According to the three different approaches (study-level, patient-level, and follow-up analyses), the estimated annual rates of development of de novo aneurysms were 1.62% (95% CI 0.28–3.59%), 0.28% (95% CI 0.12–0.49%), and 0.92% (95% CI 0.64–1.25%), respectively. The estimated annual rate of development of second de novo aneurysms ranged from 0.28 to 1.62%.