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  • Author or Editor: Johannes Schramm x
  • Journal of Neurosurgery: Spine x
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Axel Jung, Johannes Schramm, Kai Lehnerdt and Claus Herberhold

Object. Recurrent laryngeal nerve (RLN) palsy is a well-known complication of cervical spine surgery. Nearly all previous studies were performed without laryngoscopy in asymptomatic patients. This prospective study was undertaken to discern the true incidence of RLN palsy. Because not every RLN palsy is associated with hoarseness, the authors conducted a prospective study involving the use of pre- and postoperative laryngoscopy.

Methods. Prior to anterior cervical spine surgery preoperative indirect laryngoscopy was performed in 123 patients to evaluate the status of the vocal cords as a sign of function of the RLN. To assess postoperative status in 120 patients laryngoscopy was repeated, and in cases of vocal cord malfunction follow-up examination was conducted 3 months later.

In the group of 120 patients who attended follow-up examination, two (1.6%) had experienced a preoperative RLN palsy without hoarseness. Postoperatively the rate of clinically symptomatic RLN palsy was 8.3%, and the incidence of RLN palsy not associated with hoarseness (that is, clinically unapparent without laryngoscopy) was 15.9% (overall incidence 24.2%). At 3-month follow-up evaluation the rate had decreased to 2.5% in cases with hoarseness and 10.8% without hoarseness. Thus, the overall rate of early persisting RLN palsy was 11.3%.

Conclusions. Laryngoscopy revealed that the true incidence of initial and persisting RLN palsy after anterior cervical spine surgery was much higher than anticipated. Especially in cases without hoarseness this could be proven, but the initial incidence of hoarseness was higher than expected. Only one third of new RLN palsy cases could be detected without laryngoscopy. Resolution of hoarseness was approximately 70% in those with preoperative hoarseness. The true rate of RLN palsy underscores the necessity to reevaluate the surgery- and intubation-related techniques for anterior cervical spine surgery and to reassess the degree of presurgical patient counseling.

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Rudolf A. Kristof, Ales F. Aliashkevich, Michael Schuster, Bernhard Meyer, Horst Urbach and Johannes Schramm

Object. The authors conducted a study to determine the results of decompressive surgery without fusion in selected patients who presented with radicular compression syndromes caused by degenerative lumbar spondylolisthesis and in whom there was no evidence of hypermobility on flexion—extension radiographs.

Methods. The medical records and radiographs obtained in 49 patients were reviewed retrospectively. Clinical status was quantified by summing self-assessed Prolo Scale scores. All 49 patients (55% female, mean age 68.7 years) presented with leg pain accompanied by lumbalgia in 85.7% of the cases. Preoperatively the median sum of Prolo Scale scores was 4. The mean preoperative degree of forward vertebral displacement was 13.5% and was located at L-4 in 67% of the cases. Osseous decompression alone was performed in 53%, and an additional discectomy at the level of displacement was undertaken in the remaining patients because of herniated discs. Major complications (deep wound infection) occurred in 2%. During a mean follow-up period of 3.73 years, 10.2% of the patients underwent instrumentation-assisted lumbar fusion when decompression alone failed to resolve symptoms. At last follow up the median overall Prolo Scale score was 8. Excellent and good results were demonstrated in 73.5% of the patients. Prolonged back pain (r = 0.381) as well as the preoperative degree of displacement (r = 0.81) and disc space height (r = 0.424) influenced outcome (p ≤ 0.05); additional discectomy for simultaneous disc herniation at the displaced level did not influence outcome (p > 0.05).

Conclusions. These results appear to support a less invasive approach in this subgroup of elderly patients with degenerative lumbar spondylolisthesis—induced radicular compression syndromes and without radiographically documented hypermobility. Additional discectomy for simultaneous disc herniation of the spondylolisthetic level did not adversely influence the outcome. Complication rates are minimized and fusion can eventually be performed should decompression alone fail. A prospective controlled study is required to confirm these results.

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Azize Boström, Timo Krings, Franz J. Hans, Johannes Schramm, Armin K. Thron and Joachim M. Gilsbach

Object

Glomus-type spinal arteriovenous malformations (AVMs) are rare. In the literature only small series and anecdotal reports can be found, and there are no prospective series elucidating the natural course or the superiority of 1 treatment regimen over another (such as surgery versus embolization versus conservative treatment). Microsurgical treatment of spinal AVMs often seems difficult because many lesions are not anatomically suitable for primary microsurgical occlusion and are therefore treated with first-line neuroradiological interventions or not at all.

Methods

Between 1989 and 2005, 20 patients with glomus-type AVMs underwent microsurgical treatment at 2 major neurosurgical centers in Germany. The history of symptoms in these patients ranged from 2 days to 11 years. Four patients presented with subarachnoid hemorrhage, 2 with intramedullary hematoma, 4 with paresthesia or pain, and 10 with clinical signs of myelopathy. Seven patients underwent partial embolization prior to microsurgery. The authors only operated on AVMs accessible from a dorsal or dorsolateral approach. Neurological status was assessed with the McCormick classification scheme. Follow-up data were obtained from outpatient records. Three patients were interviewed over the telephone and 4 patients were not available for follow-up evaluation.

Results

Surgery was performed via a laminectomy in 14 and hemilaminectomy in 6 patients. The microsurgical technique used consisted of retrograde dissection of the AVM from the venous side in most cases. Four (20%) of 20 patients showed worsening of neurological symptoms to a worse McCormick grade, probably caused by suspected venous stasis directly after surgery, however only 1 patient (5%) suffered permanent deterioration after surgery. In 14 patients postoperative angiography proved complete occlusion in 11 patients, including the presence of a remnant requiring a second operation with complete occlusion thereafter in 1 patient. In 3 patients occlusion was incomplete: a small residual AVM remained in 1 patient, and a discrete feeding vessel without a vein was evident in 2 patients.

Conclusions

Spinal cord AVMs are rare. If embolization is not possible, surgery may be indicated in selected cases. Spinal AVMs behave differently after incomplete occlusion either surgically or with embolization. A postoperative reduction in symptoms is frequent despite the presence of small remnants, and the risk of neurological deficits seems relatively low even in residual AVMs. Therefore, treatment need not necessarily aim at complete occlusion if that would be associated with an unacceptably high risk of neurological deficits.