bluuebunny/crossref_metadata_2025 huggingface dataset:
The independent effect of gender on outcomes following traumatic brain injury: a preliminary investigation
Authors: Kraus Jess F. , Peek-Asa Corinne , McArthur David
Published: January 2008

Although epidemiological studies of gender differences in outcome after brain injury are limited, studies in animals indicate higher fatality rates for females. Studies in which healthy human brain metabolism was investigated also suggest gender differences. In this paper the authors examine gender as an independent predictor of survival following brain injury. A prospective cohort of severely and moderately brain injured individuals was identified from two trauma centers over a period of 3.5 years. Patients enrolled in the cohort were followed for as long as 18 months postdischarge. The Glasgow Outcome Scale was used to measure long-term outcome. Overall, mortality was 1.28 times higher in females than males, with the greatest difference of 2.14 found in deaths postdischarge. Controlling for age, admission Glasgow Coma Score, penetrating as compared with blunt injury, and the presence of multiple trauma, females were 1.75 times more likely than males to die of their brain injury (95% confidence interval 1.09—2.82). Furthermore, females were 1.57 times more likely to experience poor outcomes (that is, severe disability or persistent vegetative state) than males. These findings suggest the need to examine similar effects in different cohorts and to identify the patho-physiological basis for the differences observed in this epidemiological study.
Are steroids really ineffective for severely head injured patients?
Authors: Kamano Shuji
Published: January 2008

The “Guidelines for the Management of Severe Head Injury” states that the use of glucocorticoids is not recommended for improving morbidity outcome. Conversely, the “National Acute Spinal Cord Injury Study” (NASCIS) in the United States concluded that treatment with very high doses of methylprednisolone (30 mg/kg) is indicated for acute spinal cord trauma. In this paper the author will discuss the reasons for this great discrepancy between head injuries and spinal cord traumas. A 30-mg dose of methylprednisolone was used as a bolus dose in the spinal cord study to inhibit oxygen free radical-induced lipid peroxidation. In most of the papers cited containing Class I data on severe head injury studies the investigators used smaller doses of glucocorticoids as compared with those in the spinal cord study. Moreover, some of the papers included cases in which the time from insult to the initiation of treatment had been poorly controlled. Therefore, based on previous papers, it is appropriate to relinquish megadose steroid therapy for head injury patients. A good prospective multicenter trial of high-dose methylprednisolone for traumatic brain injury should be considered in which dosage and timing parameters similar to those enacted for the NASCIS studies are used.
Evaluating the outcome of severe head injury with transcranial Doppler ultrasonography
Authors: Moreno José A. , Mesalles Eduard , Gener Juan , Tomasa Antonio , Ley Adolfo , Roca Josep , Fernández-Llamazares Jaime
Published: January 2008

The authors conducted a study to determine the value of transcranial Doppler (TCD) ultrasonography in evaluating the outcome of severely head injured patients and to correlate the TCD values with those obtained from intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring.

The authors conducted a prospective study of 125 patients with severe head injury (Glascow Coma Scale scores of less than 9) who underwent TCD ultrasonography according to the standard technique of insonating the middle cerebral artery (MCA) and measuring the mean blood flow velocity and pulsatility index within the first 24 hours of admission. The ICP and CPP values, as well as other clinical, analytical, and neuroimaging data, were also recorded. After 6 months, outcome was evaluated using the Glasgow Outcome Scale. Moderate disability and complete recovery were considered “good” outcome; death, vegetative state, and severe disability were considered “poor.”

In 67 patients (54%) good outcome was demonstrated whereas in 58 (46%) it was poor. The mean blood flow velocity of the MCA in patients with good outcome was 44 cm/second; in those with poor outcomes it was 36 cm/second (p < 0.003). The mean PI in cases of good outcome was 1 whereas in poor outcome was 1.56 (p < 0.0001). The correlations of ICP and CPP to PI were statistically significant (r2 = 0.6; p < 0.0001).

When performed in the first 24 hours of severe head injury, TCD ultrasonography is valid in predicting the patient’s outcome at 6 months and correlates significantly with ICP and CPP values.
High extracellular potassium and its correlates after severe head injury: relationship to high intracranial pressure
Authors: Reinert Michael , Khaldi Ahmad , Zauner Alois , Doppenberg Egon , Choi Sung , Bullock Ross
Published: January 2008

Disturbed ionic and neurotransmitter homeostasis are now recognized to be probably the most important mechanisms contributing to the development of secondary brain swelling after traumatic brian injury (TBI). Evidence obtained from animal models indicates that posttraumatic neuronal excitation via excitatory amino acids leads to an increase in extracellular potassium, probably due to ion channel activation. The purpose of this study was therefore to measure dialysate potassium in severely head injured patients and to correlate these results with intracranial pressure (ICP), outcome, and also with the levels of dialysate glutamate, lactate, and cerebral blood flow (CBF) so as to determine the role of ischemia in this posttraumatic ionic dysfunction.

Eighty-five patients with severe TBI (Glasgow Coma Scale score < 8) were treated according to an intensive ICP management-focused protocol. All patients underwent intracerebral microdialyis. Dialysate potassium levels were analyzed by flame photometry, as were dialysate glutamate and dialysate lactate levels, which were measured using high-performance liquid chromatography and an enzyme-linked amperometric method in 72 and 84 patients respectively. Cerebral blood flow studies (stable Xenon–computerized tomography scanning) were performed in 59 patients.

In approximately 20% of the patients, potassium values were increased (dialysate potassium > 1.8 mmol). Mean dialysate potassium (> 2 mmol) was associated with ICP above 30 mm Hg and fatal outcome. Dialysate potassium correlated positively with dialysate glutamate (p < 0.0001) and lactate levels (p < 0.0001). Dialysate potassium was significantly inversely correlated with reduced CBF (p = 0.019).

Dialysate potassium was increased after TBI in 20% of measurements. High levels of dialysate potassium were associated with increased ICP and poor outcome. The simultaneous increase of potassium, together with dialysate glutamate and lactate, supports the hypothesis that glutamate induces ionic flux and consequently increases ICP due to astrocytic swelling. Reduced CBF was also significantly correlated with increased levels of dialysate potassium. This may be due to either cell swelling or altered potassium reactivity in cerebral blood vessels after trauma.
Combined magnetic resonance imaging– and positron emission tomography–guided stereotactic biopsy in brainstem mass lesions: diagnostic yield in a series of 30 patients
Authors: Massager Nicolas , David Philippe , Goldman Serge , Pirotte Benoît , Wikler David , Salmon Isabelle , Nagy Nathalie , Brotchi Jacques , Levivier Marc
Published: January 2008

In the management of brainstem lesions, the place of stereotactic biopsy sampling remains debatable. The authors compared the results of magnetic resonance (MR) imaging, positron emission tomography (PET), and histological findings obtained in 30 patients who underwent an MR image– and PET-guided stereotactic biopsy procedure for a brainstem mass lesion.

Between July 1991 and December 1998, 30 patients harboring a brainstem mass lesion underwent a stereotactic procedure in which combined MR imaging and PET guidance was used. Positron emission tomography scanning was performed using [18F]-fluorodeoxyglucose in 16 patients, methionine in two patients, and with both tracers in 12 patients. Definite diagnosis was established on histological examination of the biopsy samples. Interpretation of MR imaging findings only or PET findings only were in agreement with the histological diagnosis in 63% and 73% of cases, respectively. Magnetic resonance imaging and PET findings were concordant in 19 of the 30 cases; in those cases, imaging data correlated with histological findings in 79%. In seven patients who underwent one PET-defined and one MR imaging–defined trajectory, at histological examination the PET-guided samples were more representative of the tumor's nature and grade than the MR imaging–guided samples in four cases (57%). In 18 patients PET scanning was used to define a biopsy target and provided a diagnostic yield in 100% of the cases.

Although the use of combined PET and MR imaging improves radiological interpretation of a mass lesion in the brainstem, it does not accurately replace histological diagnosis that is provided by a stereotactically obtained biopsy sample. Combined information provided by MR imaging and PET in stereotactic conditions improves the accuracy of targeting and the diagnostic yield of the stereotactically biopsy sample; an MR imaging– and PET-guided stereotactic biopsy procedure is a safe and efficient modality for the management of mass lesions of the brainstem.
Use of fluorodeoxyglucose–positron emission tomography for the differentiation of cerebral lesions in patients with acquired immune deficiency syndrome
Authors: Menendez Jose A. , Lilien David L , Nanda Anil , Polin Richard S.
Published: January 2008

Intracranial mass lesions comprise approximately half of all acquired immune deficiency syndrome (AIDS)–related neurological complications. Although toxoplasmosis and lymphoma are the most common causes of these lesions, diagnosis and treatment can be delayed because computerized tomography and magnetic resonance imaging studies cannot accurately differentiate between them.

The authors retrospectively studied nine patients with AIDS in whom, after a 6-hour fast, [18F]-fluorodeoxyglucose (FDG)–positron emission tomography (PET) scanning demonstrated intracranial mass lesions. The FDG uptake within each lesion was classified as either increased or not increased. In six patients there was no increase in FDG uptake, which suggested a diagnosis of toxoplasmosis, and lymphoma was suggested in two patients in whom increased FDG uptake was demonstrated. In a patient with two lesions, one lesion was shown to have increased FDG uptake whereas the other was shown to have no increased FDG uptake. All patients in whom a diagnosis of toxoplasmosis was made were started on antimicrobial therapy. Two patients died of other AIDS-related complications before repeated neuroimaging could be performed to assess treatment response, one patient refused to undergo further treatment or follow up, and two patients responded well to treatment. One patient with toxoplasmosis did not respond to the drugs. Analysis of a biopsy sample of the lesion confirmed the diagnosis; however, the patient died shortly thereafter. The two patients with FDG-PET–diagnosed lymphoma began corticosteroid therapy and improved considerably. In the patient in whom PET demonstrated two different FDG uptakes, a biopsy sample was obtained that confirmed the diagnosis of lymphoma; this patient was started on corticosteroid therapy and improved. A safe and reliable diagnostic tool, FDG-PET scanning can be used to differentiate causes of human immunodeficiency virus-related intracranial mass lesions. When available, this diagnostic study should be conducted before initiating empirical treatment or obtaining a stereotactically guided brain biopsy sample.
Functional brain mapping using positron emission tomography scanning in preoperative neurosurgical planning for pediatric brain tumors
Authors: Kaplan Allen M. , Bandy Daniel J. , Manwaring Kim H. , Chen Kewei , Lawson Michael A. , Moss S. David , Duncan Johnny D. , Wodrich David L. , Schnur James A. , Reiman Eric M.
Published: January 2008

Object

The purpose of this report is to demonstrate the value of functional brain mapping using the positron emission tomography (PET) method for preoperative neurosurgical planning in children with brain tumors. Brain maps were used to characterize the relationship between potentially resectable tumors and functionally eloquent brain areas.

Methods

Five children, ranging in age from 3 to 13 years, with hemispheric brain tumors adjacent to eloquent cortex were studied. Magnetic resonance (MR) imaging was used to identify the brain tumors; PET imaging after injection of [18F]fluorodeoxyglucose (FDG), [11C]l-methionine (CMET), or a combination of the two was performed to grade the tumors; and a [15O] H2O uptake study was used to characterize the anatomical relationships of the tumors to functional cortex. The cortical activation maps were obtained during control periods and during behavioral tasks and were used to document motor, visual, and speech and language organizational areas. Wada tests were performed in two patients. Language and speech activation was concordant with the results of Wada testing.

Conclusions

Functional brain mapping using PET scans and coregistered MR images provided the neurosurgeon with precise definitions of structural and functional cortical areas; this altered surgical management in some cases and/or was used to predict outcome. The combination of PET imaging with FDG and/or CMET and measurements of [15O] water uptake was useful in characterizing and grading tumors and instrumental in achieving effective neurosurgical planning. Postoperative results in the five cases suggest that preoperative functional brain mapping has the potential to improve outcome by defining a surgical plan to maximize resection and minimize the risk of neurological sequelae.
Classification of syringomyelia
Authors: Milhorat Thomas H.
Published: January 2008

Syringomyelia poses special challenges for the clinician because of its complex symptomatology, uncertain pathogenesis, and multiple options of treatment. The purpose of this study was to classify intramedullary cavities according to their most salient pathological and clinical features.

Pathological findings obtained in 175 individuals with tubular cavitations of the spinal cord were correlated with clinical and magnetic resonance (MR) imaging findings in a database of 927 patients. A classification system was developed in which the morbid anatomy, cause, and pathogenesis of these lesions are emphasized.

The use of a disease-based classification of syringomyelia facilitates diagnosis and the interpretation of MR imaging findings and provides a guide to treatment.
Application of syringosubarachnoid shunt through key-hole laminectomy
Authors: Gezen Ferruh , Kahraman Serdar , Ziyal Ibrahim M. , Çanakçi Zafer , Bakir Abdurrahman
Published: January 2008

The authors describe the key-hole laminectomy technique (KHLT) for application of syringosubarachnoid shunts. This technique was used in 29 patients with noncommunicating syringomyelia. In all cases the shunts were inserted successfully without any peri- or late postoperative complications. The late follow-up magnetic resonance examinations revealed the clear collapse of syrinx in all cases. The authors advocate use of the KHLT because it is associated with less surgery-related trauma, epidural fibrosis, infection, and spinal instability.
Toward a rational treatment of Chiari I malformation and syringomyelia
Authors: Ellenbogen Richard G. , Armonda Rocco A. , Shaw Dennis W. W. , Winn H. Richard
Published: January 2008

In patients with Chiari I malformation with and without associated syringomyelia, aberrant cerebrospinal fluid (CSF) dynamics and a spectrum of posterior fossa pathological findings are demonstrated. In this study, the authors test the validity of using prospective cardiac-gated phase-contrast cine-mode magnetic resonance (MR) imaging to define the malformation, delineate its pathophysiology, and assist in implementing a rational treatment plan.

Eighty-five cases were prospectively analyzed using cine MR imaging. Sixty-five patients, adults and children, with symptomatic Chiari malformation, with and without syringomyelia, were surgically treated from 1990 to 1999. All patients underwent pre- and postoperative cine MR evaluation. Ten patients were treated after a previous surgical procedure had failed. To establish CSF flow characteristics and normative CSF profiles, 20 healthy volunteers were examined.

Compared with normal volunteers, in Chiari I malformation patients with and without syringomyelia, uniformly abnormal craniocervical junction CSF flow profiles were revealed. After intradural exploration, nearly all patients with Chiari I malformation experienced clinical improvement and CSF flow profiles, paralleling those of normal volunteers, were shown. In all patients in whom treatment had failed, abnormal preoperative CSF flow profiles, which correlated with suspected physiological abnormalities and the pathological findings noted at reoperation, were demonstrated.

Symptomatic Chiari I malformation is a dynamic process characterized by the impaction of the hindbrain in an abnormal posterior fossa. This compression obstructs the normal venting of CSF in and out of the craniocervical sub-arachnoid space, throughout the cardiac cycle. Therefore, decompression or enlargement of the posterior fossa to establish normal CSF pathways should be the primary goal of surgical intervention. Aberrant CSF flow appears to be only one aspect of the pathological condition found in patients with Chiari I malformation. Arachnoid scarring in the posterior fossa and selective vulnerability of the spinal cord may also be factors in the pathogenesis and maintenance of associated syringomyelia. Phase-contrast cine MR imaging is a useful tool in defining physiological and anatomical problems in patients with Chiari I and syringomyelia, and it can help guide an appropriate primary or salvage surgical therapy.
Primary spinal syringomyelia: a personal perspective
Authors: Batzdorf Ulrich
Published: January 2008

In this paper the author summarizes currently available surgical approaches to spinal syringomyelia that is unrelated to Chiari I malformation or hindbrain descent. Primary spinal syringomyelia is most comonly associated with spinal trauma but is also encountered as a sequela to intradural inflammatory processes (infections or chemical), as a delayed response to surgical procedures, and in association with intra- and extradural neoplasms as well as disc protrusions. The advantages of placing a shunt are its technical simplicity and immediate reduction of syrinx size; its major disadvantages are the high rate of failure observed in long-term follow up and the difficulty in applying this technique in septated cysts. Expansion of the subarachnoid space with resection of scars has better long-term results. Patients in whom a syrinx cavity has caused a kyphotic spinal deformity may need to undergo a procedure in which the kyphotic deformity is corrected to expand the subarachnoid space. Cyst obliteration is an experimental approach that cannot be evaluated at the present time.
Treatment of posttraumatic syringomyelia with extradural decompressive surgery
Authors: Holly Langston T. , Johnson J. Patrick , Masciopinto Jeffrey E. , Batzdorf Ulrich
Published: January 2008

The authors review the management of five patients with posttraumatic syringomyelia (PTS) associated with an uncorrected spinal deformity. Patients with evidence of progressive neurological deterioration underwent ventral spinal decompressive surgery.

The mean patient age at the time of injury was 39 years, and the time between injury and the diagnosis of PTS ranged from 2 to 22 years. Mechanisms of injury consisted of fracture/subluxations in three patients and burst fractures in two. All patients experienced delayed neurological deterioration consistent with PTS. Magnetic resonance imaging revealed ventral deformities, and the spinal canal stenosis ranged from 20 to 50% (mean 39%). All patients underwent ventral epidural spinal decompressive surgery to correct the bone deformity and restore the spinal canal.

The mean follow-up period was 38 months. The decompressive intervention was initially successful in treating the neurological deterioration in all patients. Symptoms resolved completely in four patients, and the other experienced neurological improvement. Postoperative magnetic resonance imaging revealed a reduction in the size of syrinx cavity in the patients whose symptoms resolved and no change in the remaining patient. Two patients required a subsequent second-stage posterior intradural exploration and duraplasty for recurrence of symptoms and/or syrinx.

Posttraumatic spinal deformity may cause spinal canal stenosis and alter subarachnoid cerebrospinal fluid (CSF) flow in certain patients. Ventral epidural spinal decompressive surgery may result in neurological improvement and a reduction of the syrinx cavity, avoiding the need for placement of a shunt or other intradural procedures. However, some patients will also require reconstruction of the posterior subarachnoid space with duraplasty if the ventral decompressive procedure achieves only partial restoration of the subarachnoid CSF flow.
Gene therapy of brain tumors: problems presented by physiological barriers
Authors: Basilion James P. , Ichikawa Tomotsuga , Chiocca E. Antonio
Published: January 2008

The explosion of molecular techniques for gene discovery and their application to a variety of diseases has uncovered numerous gene abnormalities that can result in disease. These discoveries have provided the needed understanding and genetic materials to apply gene therapy approaches in the treatment of several diseases, including those of the central nervous system. A variety of different anticancer complementary DNAs (cDNA) have been shown to possess biological efficacy when used in the appropriate experimental setting. However, efficient and effective delivery of these cDNAs remains a major obstacle for future clinical applications. The focus of this review will be to describe the obstacles that impede the process of gene therapy and oncolytic viral therapy of brain tumors and to describe how important new discoveries derived from other disciplines are being used to address problems encountered in the gene/ viral therapy of this disease.
A light and electron microscopic study of ectopic tendon and ligament formation induced by bone morphogenetic protein–13 adenoviral gene therapy
Authors: Helm Gregory A. , Li Jin Zhong , Alden Tord D. , Hudson Sarah A. , Beres Elisa J. , Cunningham Mary , Mikkelsen Mark M. , Pittman Debra D. , Kerns Kelvin M. , Kallmes David F.
Published: January 2008

Object

Bone morphogenetic proteins (BMPs) are involved in the growth and development of many tissues, but it is their role in skeletal development and their unique ability to induce ectopic and orthotopic osteogenesis that has attracted the greatest interest. Expression of the BMP-13 gene has been shown to be predominantly localized to hypertrophic chondrocytes in regions of endochondral bone formation during development, as well as in mature articular cartilage in the adult. In addition, the application of BMP-13 on a collagen carrier induces neotendon/ligament formation when delivered subcutaneously or intramuscularly in rodents. The aim of the present study was to determine the histological and ultrastructural changes that occur after the intramuscular injection of a first-generation BMP-13 adenoviral vector.

Methods

Athymic nude rats were injected with 3.75 × 1010 plaque-forming unit adenovirus (Ad)-BMP-13 or Ad-β-galactosidase in the thigh musculature, and the regions examined using light and electron microscopy at various time points between 2 and 100 days postinjection. As early as 2 days after injection of Ad-BMP-13, progenitor cells were observed infiltrating between the transduced muscle fibers. These cells subsequently proliferated, differentiated, and secreted large amounts of collagenous extracellular matrix. By 100 days postinjection, the induced tissue had the histological and ultrastructural appearance of neotendon/ligament, which was clearly demarcated from the surrounding muscle. Small foci of bone and fibrocartilage were also seen within the induced tissue. A short-term bromodeoxyuri-dine study also demonstrated rapid mesenchymal cell proliferation at the Ad-BMP-13 injection site as early as 48 hours postinjection.

Conclusions

The results of this study suggest that in the future the use of the BMP-13 gene may have therapeutic utility for the healing of tendon and ligament tears and avulsion injuries.
Evaluation of big endothelin–1 concentrations in serum and ventricular cerebrospinal fluid after early surgical compared with nonsurgical management of ruptured intracranial aneurysms
Authors: Gruber Andreas , Roessler Karl , Georgopoulos Apostolos , Mißbichler Albert , Bonelli Raphael , Richling Bernd , Bavinzski Gerhard , Czech Thomas
Published: January 2008

Object

Whereas the removal of subarachnoid blood is possible during early-stage aneurysm surgery, this cannot be achieved in aneurysms treated by endovascular means. The levels of potential spasmogens in the cerebrospinal fluid (CSF) in patients receiving endovascular treatment might therefore be higher, with the potential for more severe post–subarachnoid hemorrhage (SAH) vasospasm.

Methods

Serum and CSF concentrations of big endothelin (ET)–1 were serially measured in patients with SAH receiving one of the following treatments: 1) early (within 72 hours of SAH) aneurysm surgical treatment (15 patients), 2) early endovascular treatment (17 patients), or 3) no intervention in the acute phase (12 patients). In patients suffering delayed infarctions higher levels of big ET–1 CSF were demonstrated than in those without infarctions (p = 0.01). In patients in whom surgery was performed in the acute phase lower big ET–1 CSF concentrations were demonstrated than in those who received embolization treatment or no treatment (p = 0.02). Subgroup analysis demonstrated that in patients receiving early endovascular treatment, higher big ET–1 CSF concentrations were revealed than in those undergoing early aneurysm surgery; this was true for patients with (microsurgery-treated, 1.84 ± 0.83 pg/ml; and embolization-treated 2.19 & plusmn; 0.54 pg/ml) and without (microsurgery-treated 1.76 & plusmn; 0.61 pg/ml; and embolization-treated 2.01 ± 0.48 pg/ml) delayed infarctions.

Conclusions

Among patients with SAH who received treatment during the acute phase, those undergoing early aneurysm surgery were shown to have lower big ET–1 CSF levels than those receiving embolization and no treatment (that is, the nonsurgical treatment groups). The clinical significance of this finding remains to be established in future clinical trials, because in the present study the trend toward lower levels of big ET–1 CSF in the microsurgically treated group was not paralleled by a lower delayed stroke rate or an improvement in neurological outcome.
Introduction to odontoid fractures: controversies in the management of odontoid fractures
Authors: Przybylski Gregory J.
Published: January 2008

Although odontoid fractures were first classified more than 25 years ago,5 the management of these fractures remains controversial. Whereas the nonoperative management with external immobilization devices often leads to successful healing, certain fracture features and patient characteristics have been associated with an increased risk of bone nonunion.6,17 Recent technological advances in cervical spine instrumentation techniques have provided additional options for the management of these common fractures.1,12,13,24,27,28 However, an absence of rigorous studies in which the investigators compare management methods may contribute to the varying methods used by spine surgeons when approaching similar injuries.

In this issue of Neurosurgical Focus, various aspects of the management of odontoid fractures are examined. In an evidence-based analysis of methods for treating odontoid fractures the authors examine the best available published data to determine the level of scientific data supporting the use of various treatment options.3 In epidemiological studies the investigators examine factors contributing to the unusual incidence of spinal cord injury with odontoid fractures as well as the unique considerations that may be attendant on the management of posteriorly displaced fractures. In two other studies the authors discuss the application of specific surgical techniques in treating odontoid fractures, whereas in an additional two reports the authors evaluate the difficulties in managing elderly patients with these injuries. Finally, the use of newer osteoinductive agents is examined as a potential adjunct in the surgical management of bony defects in the dens.
Type II odontoid fractures in the elderly: early failure of nonsurgical treatment
Authors: Kuntz Charles , Mirza Sohail K. , Jarell Abel D. , Chapman Jens R. , Shaffrey Christopher I. , Newell David W.
Published: January 2008

The optimum treatment of Type II odontoid fractures in the geriatric population remains controversial. Coexisting medical conditions encountered in the elderly patient often increase operative risk and make cervical immobilization difficult to tolerate. Previous studies have shown increased morbidity and mortality and decreased fusion rates for Type II odontoid fractures treated with cervical orthoses in the geriatric population, whereas low morbidity and mortality rates with operative management have recently been documented. To investigate the role of surgical and nonsurgical treatment, a retrospective analysis was performed of patients with Type II odontoid fractures who were at least 65 years old and were consecutively admitted to a single medical center from 1994 to 1998. Twenty patients met inclusion criteria. In 12 patients nonsurgical management with a cervical orthosis was attempted. The nonsurgical management failed early in six patients, with one associated death. Eleven patients were treated surgically with either anterior odontoid screw fixation or posterior C1–2 transarticular screw fixation and modified Gallie fusion. Postoperatively one patient required revision of the C1–2 transarticular screws, and there was one death. In conclusion Type II odontoid fractures in this elderly population were associated with early 10% morbidity and 20% mortality rates. Nonsurgical management of Type II odontoid fractures failed early in six (50%) of 12 patients, whereas surgical treatment failed early in one of 11 (9%) patients. Both the nonsurgical and surgical treatments resulted in approximately 10% morbidity and 10% mortality rates.
Surgical treatment of complex traumatic frontobasal lesions: personal experience in 74 patients
Authors: Piek Jürgen
Published: January 2008

Object

The author's personal series included 148 patients who sustained traumatic frontobasal injuries and were treated between 1986 and 1999. Included in this study are 74 of 148 patients with acute injuries and complex fronto-basal lesions involving the frontal sinus, the cribriform/ethmoid roof complex, one or both orbital roofs, and the planum sphenoidale.

Methods

Surgery was delayed for up to 4 weeks postinjury in most patients (67 cases), whereas 17 with space-occupying hematomas and perforating injuries required early surgery. In 30 patients additional surgery was required to treat maxillofacial fractures, which was performed as a one-stage procedure together with the neurosurgical operation. The author performed a standard bifrontal craniotomy in which an intradural or combined intradural–extradural approach was used in all cases.

Four patients developed ascending meningitis in the preoperative period. As a result of surgical treatment one patient died, another two patients suffered from permanent defects, and three suffered from transitory neurological worsening. In two patients recurrence of a cerebrospinal fluid fistula occurred within a 3-month period posttreatment but was successfully obliterated during reoperation.

In the author's experience the intradural approach is comparable in terms of the morbidity, mortality, and success rates with extracranial approaches; additionally the intradural approach provides full visualization of the intracranial lesion. Useful olfactory nerve function can only be preserved if both olfactory nerves are left intact and not crushed during initial injury; this occurred in only five patients in this series.

Conclusions

If possible, surgical treatment of more complex lesions should be delayed until the 2nd or 3rd week following traumatic injury. With antibiotic prophylaxis the risk that ascending meningitis will occur prior to surgery is low. If the patient is systemically stable and brain swelling has resolved, even extensive one-stage neurosurgical/ maxillofacial procedures are well tolerated.
Surgical treatment of spontaneous spinal cerebrospinal fluid leaks
Authors: Maher Cormac O. , Meyer Fredric B. , Mokri Bahram
Published: January 2008

Spontaneous spinal cerebrospinal fluid (CSF) leaks are an increasingly recognized cause of intracranial hypotension. In this report the authors review the indications for surgery, surgical techniques, and surgery-related outcomes for these lesions. The major presenting symptoms include postural headaches, nausea, vomiting, and diplopia. Often, there is no history of traumatic injury. The most common cranial magnetic resonance (MR) imaging features include pachymeningeal gadolinium enhancement and sagging of the brain. On spinal MR images, diverticula are frequently noted. In cases in which symptoms are severe and refractory to less invasive measures, surgical intervention is indicated. Tears in the dura or leaking diverticula that are identified as the sources of the CSF leak often can be ligated or repaired. When a source of CSF egress is not found intraoperatively, packing the epidural space with blood-soaked Gelfoam or muscle at the appropriate level can lead to relief of symptoms. Occasionally the dural defect is large, irregular, or has attenuated borders that may not be possible to repair with sutures. These may be repaired by packing the defect with muscle or blood-soaked Gelfoam. Indications for and outcomes of surgery in patients with this condition will become more defined as surgeons gain experience with these procedures.
Spontaneous spinal cerebrospinal fluid leaks: a review
Authors: Schievink Wouter I.
Published: January 2008

Spontaneous intracranial hypotension has become a well-recognized clinical entity, but it remains an uncommonly, and probably underdiagnosed, cause of headache; its estimated prevalence is only one in 50,000 individuals. The clinical spectrum of spontaneous intracranial hypotension is quite variable and includes headache, neck stiffness, cranial nerve dysfunction, radicular arm pain, and symptoms of diencephalic or hindbrain herniation. Leakage of the spinal cerebrospinal fluid (CSF) is the most common cause of spontaneous intracranial hypotension. A combination of an underlying weakness of the spinal meninges and a more or less trivial traumatic event is often found to cause this event in these patients. Typical magnetic resonance imaging findings include diffuse pachymeningeal enhancement, sub-dural fluid collections, and downward displacement of the brain, sometimes mimicking a Chiari I malformation. Opening pressure is often, but not always, low, and examination of CSF may reveal pleocytosis, an elevated protein count, and xanthochromia. The use of myelography computerized tomography scanning is the most reliable method for the accurate localization of the CSF leak. Most CSF leaks are found at the cervicothoracic junction or in the thoracic spine. The initial treatment of choice is a lumbar epidural blood patch, regardless of the location of the CSF leak. If the epidural blood patch fails, the blood patch procedure can be repeated at the lumbar level, or a blood patch can be directed at the exact site of the leak. Surgical repair of the CSF leak is safe and generally successful, although a distinct structural cause of the leak often is not found.
Treatment of the subarachnoid–pleural fistula
Authors: Ozgen Serdar , Boran Burak O. , Elmaci Ilhan , Ture Ugur , Pamir M. Necmettin
Published: January 2008

Subarachnoid–pleural fistula is a rare type of cerebrospinal fluid (CSF) fistula, and there are only several cases reported in the literature. The authors describe a 65-year-old male patient in whom a diagnosis of T7–8 disc herniation had been made. He underwent surgery via a right lateral extracavitary approach. Postoperatively he developed progressive respiratory distress and headache. A chest x-ray film revealed a pleural effusion, and computerized tomography (CT) myelography demonstrated a subarachnoidal-pleural fistula at the level at which the herniated disc had been removed. The patient had been managed via a CSF drainage system and a chest tube. He was discharged after relief of symptoms was attained. Subarachnoid–pleural fistulas can be secondary to traumatic injury and surgery, or they can be spontaneous. Patients present with rapidly filling pleural effusion and headache. A diagnosis can be established using CT myelography or myeloscintigraphy. Treatment is conservative, with the placement of a chest tube and insertion of a CSF drainage catheter, and surgical repair should be considered only if the conservative therapy fails.
Dynamic orthotic cranioplasty: treatment of the older infant.
Authors: Littlefield Timothy R. , Pomatto Jeanne K. , Kelly Kevin M.
Published: January 2008

The Dynamic Orthotic Cranioplasty Band is a cranial orthotic device used to treat deformational plagiocephaly in infants. The device works by applying a mild holding pressure to the most anterior and posterior prominences, where growth is not desired, while encouraging growth in adjacent flattened regions. Although this technique has been successfully used to treat infants as young as 3 months of age, it is often assumed that decreasing cranial growth and increasing cranial rigidity prohibit treatment in infants older than 1 year of age.

The authors' experience with older infants suggests the contrary. Through a series of case reports, they present evidence that this treatment remains viable during the 2nd year of life and that improvement has been observed in infants in whom treatment has been initiated as late as 18 months. These examples certainly suggest that additional prospective studies are warranted.
Thoracoscopic surgery: historical perspectives
Authors: Das Kaushik , Rothberg Martin
Published: January 2008

Recent technical advances have revolutionized the fields of surgical endoscopy, laparoscopy, thoracoscopy, and microsurgical spinal endoscopy. The authors discuss the rich history and recent evolution of these techniques.

Thoracoscopy had been widely used for the treatment of pleural conditions associated with tuberculosis. It was largely abandoned in the 1950s when effective antituberculosis medications were introduced. In the 1980s the development of video-assisted endoscopic procedures in the fields of general surgery, orthopedics, and otolaryngology provided new impetus to revive thoracoscopy. As a result of these advances thoracoscopy replaced open thoracotomy in many cardiothoracic procedures.

These improvements led to the application of these techniques to treat disorders of the spine. By the mid-1990s microsurgical endoscopy was being used effectively to treat thoracic disc disease, perform anterior surgical release procedures for scoliosis, resect tumors, and even to conduct complex spinal fusions and reconstructions. As technology continues to improve, there is no doubt that thoracoscopic surgery will find a permanent place in the armamentarium of techniques used to treat pathological entities of the spine.
Surgery for thoracic disc disease. Complication avoidance: overview and management
Authors: McCormick William E. , Will Steven F. , Benzel Edward C.
Published: January 2008

The operative approach for discectomy in the treatment of thoracic disc disease has changed from standard laminectomy to a variety of dorsolateral and ventral approaches. The procedure-related complications have been reported in numerous clinical studies over the last seven decades: death, neurological deterioration, postoperative vertebral column instability, incomplete disc resection, cerebrospinal fluid leak and fistula, infection, misdiagnosis, pulmonary embolism, pneumonia, and intercostal neuralgia. The authors conducted a Medline search to identify series reporting clinical data related to thoracic discectomy. They analyzed the morbidity and mortality resulting from the various surgical approaches for thoracic disc disease, with special attention to the avoidance and management of surgery-related complications.
Artificial disc technology
Authors: Bao Qi-Bin , Yuan Hansen A.
Published: January 2008

After approximately 40 years of research and development, artificial disc technology may finally be coming of age. A number of devices are either at the late stage of preclinical study or in the early stage of clinical trial, and the results are promising so far. Due to the multicomponent structure of the disc, surgeons performing disc arthroplasty have the option of replacing either the entire disc or a portion of it. The decision will be largely dependent on the pathological entity addressed, the condition of the patient's spinal disc and surrounding tissues, and the cost and potential risk of the procedure. Driven by demand, almost all the emphasis in artificial disc development has been placed on the lumbar disc, with a smaller effort directed toward the cervical disc. No attempt has been made to develop an artificial thoracic disc. However, by examining the differences and similarities in structure, anatomy, function, mechanism of degeneration, pathology, surgical technique, and complications between the lumbar and thoracic disc, the authors believe it is feasible to apply artificial disc technology in the treatment of thoracic disc disease. Nonetheless, due to the rarity of thoracic disc disease and the more stable structure of this spinal component, the demand for artificial disc or artificial nucleus technology for the thoracic disc probably will be smaller than that for lumbar disc technology.
Transpedicular approach for thoracic disc herniations
Authors: Bilsky Mark H.
Published: January 2008

Object

Patients with symptomatic herniated thoracic discs may require operation for intractable radiculopathy or functionally disabling myelopathy. In the past, laminectomy was the procedure of choice for the treatment of thoracic herniations, but it was found that the approach was associated with an unacceptably high rate of neurological morbidity. Several strategies have been developed to excise the disc without manipulating the spinal cord. The focus of this paper is the transpedicular approach.

Methods

The author retrospectively reviewed the cases of 20 consecutive patients presenting with herniated thoracic discs in whom surgery was performed via a transpedicular approach. Fourteen patients presented with acute myelopathy and six with radiculopathy. Of those with myelopathy six of six regained ambulation and six of seven regained normal bladder function. No patient with myelopathy experienced neurological worsening. In four patients presenting with radiculopathy postoperative pain resolved, and in two it remained unchanged. Three minor complications (15%) occurred. No patient suffered postoperative spinal instability–related pain or delayed kyphosis.

Conclusions

As experience accumulates in the use of multiple approaches for the treatment of thoracic disc herniations, the role of each is becoming more clearly defined. The transpedicular approach is most applicable to lateral or centrolateral calcified or soft discs. The more anterior (transthoracic or thoracoscopic) and lateral (costotransversectomy or lateral extracavitary) approaches may be more useful for excision of central calcified discs.
Endoscopic transpedicular thoracic discectomy
Authors: Jho Hae-Dong
Published: January 2008

Object

To reduce the invasiveness and risk of thoracic disc surgery, a transpedicular endoscopic approach has been created. The surgical technique and outcome of endoscopic transpedicular thoracic discectomy are reported.

Methods

The surgical technique of posterior transpedicular thoracic discectomy was modified to endoscopic transpedicular surgery. A 1.5-cm trocar was placed in the interlaminar space via a 2-cm transverse paramedian skin incision. At the ventral aspect of the spinal cord discectomy was performed under direct visualization by using a 70°-lens endoscope. This surgical technique was used in 25 patients. Twelve patients were men and 13 were women, aged 29 to 70 years (median 46 years). Myelopathy, with or without radiculopathy was present in 13 patients, radiculopathy in 10, and segmental pain in two. The follow-up periods ranged from 4 to 60 months (median 27 months).

In 12 of the 13 patients with myelopathy excellent improvement was shown postoperatively; the remaining patient suffered recurrence of symptoms after a motor vehicle accident three months postoperatively. In nine of the 10 patients with radiculopathy, pain was resolved completely. In one patient with right-sided hypochondral pain and two patients with segmental pain, relief was not achieved despite excellent results of discectomy demonstrated on postoperative magnetic resonance imaging. The average length of hospital stay was one night.

Conclusions

Endoscopic transpedicular thoracic discectomy was found to be a minimally invasive and effective surgical treatment.
Bedside microdialysis for early detection of cerebral hypoxia in traumatic brain injury
Authors: Sarrafzadeh Asita S. , Sakowitz Oliver W. , Callsen Tim A. , Lanksch Wolfgang R. , Unterberg Andreas W.
Published: January 2008

Object

The authors evaluated the use of bedside cerebral online microdialysis for the detection of impending and present cerebral hypoxia in patients who had sustained traumatic brain injury.

Methods

Thirty-five severely head injured patients (with Glasgow Coma Scale scores ≤ 8) were studied. Patients underwent continuous brain tissue PO2 (PtiO2) monitoring. The PtiO2 catheter was placed into the unaffected frontal white matter within 32.2 hours postinjury (range 7–48 hours). The microdialysis catheter was placed close to the PtiO2 probe via a 2- or 3-way skull screw that was connected to a pump and perfused with Ringer's solution at 0.3 μl/minute. The microdialysis samples were collected hourly and analyzed at the bedside for glucose, lactate, lactate–pyruvate 5-minute ratio, and glutamate. Data were analyzed for identification of episodes of impending (PtiO2 10–15 mm, Hg > 5-minute duration) and present cerebral hypoxia (PtiO2 10 mm, Hg, > 5-minute duration). In 62% of the patients hypoxic episodes occurred and were most frequently associated with hyperventilation (p < 0.001). During impending hypox-ia, extracellular glutamate concentrations were increased (p = 0.006) whereas energy metabolites remained stable. During cerebral hypoxia, the extracellular glutamate (p < 0.001) and lactate (p = 0.001) concentrations were significantly higher than during normal oxygenation, whereas the lactate–pyruvate ratio was only slightly increased (p = 0.088, not significant).

Conclusions

The authors conclude that a PtiO2 below 10 mm Hg is critical to induce metabolic changes seen during hypoxia/ischemia. Early markers of cerebral hypoxia are increased levels of glutamate and lactate. Regional hypoxia is not always associated with anaerobic cerebral metabolism. In the future, this technology of bedside monitoring may allow optimization of the treatment of severely head injured patients.