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Dimitris Zevgaridis, Claudius Thomé and Joachim K. Krauss

Object

The complications of autogenous bone grafting compel spine surgeons to seek alternative methods for cervical spinal fusion. This prospective study was conducted to evaluate the safety and efficacy of using rectangular titanium cage fusion compared with the widely performed iliac crest autograft fusion.

Methods

A total of 36 patients with cervical disc disease in whom an anterior approach was indicated for discectomy were included in this prospective controlled study. The first 18 consecutive patients received iliac crest autograft; the next 18 consecutive patients received rectangular titanium cages. The intergroup demographic and clinical data were comparable. All patients attended follow up for 1 year. According to Odom criteria, 15 (83%) of 18 patients in both groups experienced good to excellent functional recovery. According to the Patient Satisfaction Index, 17 (94%) of 18 patients in both groups were satisfied. The evaluation of neck pain and arm pain did not indicate statistically significant differences between either group. Fusion was present after 1 year in 16 (89%) of 18 patients who received iliac crest autografts and in 15 (83%) of 18 patients who received rectangular titanium cages. In the autograft group, a pseudarthrosis was present in one patient and marked hip pain was observed in three patients. In the cage group, there was one case of temporary vocal cord paresis but no implant-related complications.

Conclusions

The authors conclude that the use of titanium cages in anterior cervical discectomy constitutes a safe and efficient alternative to iliac crest bone autograft.

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Claudius Thomé, Martin Barth, Johann Scharf and Peter Schmiedek

Object. Microdiscectomy currently constitutes the standard treatment for herniated lumbar discs. Although limiting surgery to excision of fragments has occasionally been suggested, prospective data are lacking. Therefore, the objective of this study was to compare early outcome and recurrence rates after sequestrectomy and microdiscectomy.

Methods. Eighty-four consecutive patients 60 years of age or younger who harbored free, subligamentary, or transanular herniated lumbar discs refractory to conservative treatment were randomized to one of two treatment groups. Intraoperative parameters and findings were documented as well as pre- and postoperative symptoms such as pain, Patient Satisfaction Index (PSI), Prolo Scale score, and Short Form (SF)—36 subscale results. Follow up of at least 12 months was available in 73 patients (87%).

Preoperative intergroup symptoms did not differ significantly. Surgery was significantly shorter in the sequestrectomy-treated group. Overall, low-back pain and sciatica were drastically reduced in both groups and most sensorimotor deficits improved. At 4 to 6 months, SF-36 subscales and PSI scores showed a trend in favor of sequestrectomy, leaving 3% of patients unsatisfied compared with 18% of those treated with discectomy. Outcome according to the Prolo Scale was good or excellent in 76% of discectomy-treated patients and 92% of sequestrectomy-treated patients. Reherniation occurred in four patients after discectomy (10%) and two patients after sequestrectomy (5%) within 18 months.

Conclusions. Sequestrectomy does not seem to entail a higher rate of early recurrences compared with microdiscectomy. Analysis of early outcome demonstrated a trend toward superior results when sequestrectomy is performed. Although long-term follow-up data are mandatory, sequestrectomy may be an advantageous alternative to standard microdiscectomy.

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Jochen Tuettenberg, Johannes Woitzik, Leonie Siegel and Claudius Thomé

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Anja Tschugg, Sebastian Tschugg, Sebastian Hartmann, Paul Rhomberg and Claudius Thomé

A 33-year-old man presented with moderate low-back pain and L-5 radiculopathy that progressed to severe paresis of L-5. On initial imaging, a corresponding spinal lesion was overlooked. Further CT and contrast-enhanced MRI demonstrated a presacral mass along the L-5 root far extraforaminally. A herniated disc was suspected, but with standard imaging a schwannoma could not be ruled out. The presacral L-5 root was explored via a microsurgical lateral extraforaminal transmuscular approach. To the best of the authors' knowledge, there have been no reports of sequestered extraforaminal lumbosacral disc herniations that herniated into the presacral region.

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Claudius Thomé, Joachim K. Krauss, Dimitris Zevgaridis and Peter Schmiedek

✓ Intradural spinal abscesses are rare. They are predominantly encountered as intramedullary abscesses of the spinal cord and infrequently as subdural lesions.

To their knowledge, the authors report the first case of a chronic pyogenic abscess of the terminal filum in an adult woman with kyphoscoliosis who presented with lumbar radiculopathies. Magnetic resonance imaging revealed a partly cystic intradural L3–4 mass that markedly enhanced after contrast administration. Laboratory signs of infection were absent. Intraoperatively a lobulated lesion observed within the terminal filum was tightly attached to neighboring nerve roots by fibrosis. On opening the cyst wall pus was revealed. Histological examination confirmed the diagnosis of a chronic abscess. Microbiological culture detected Staphylococcus aureus. Antibiotic therapy resulted in an uneventful postoperative course, with complete resolution of symptoms and radiologically demonstrated disappearance of the lesion. The pathogenesis and radiological features of the lesion are discussed.

Although extremely rare, a pyogenic abscess should be considered in the differential diagnosis of mass lesions of the cauda equina, especially in patients with preexisting spinal abnormalities. Surgical exposure, including drainage and biopsy sampling to rule out underlying tumor, combined with antibiotic treatment result in a favorable outcome.

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Claudius Thomé, Olaf Leheta, Joachim K. Krauss and Dimitris Zevgaridis

Object

The authors compare clinical outcome and fusion rates after iliac crest autograft (ICAG)– and rectangular titanium cage (RTC)–augmented fusion in patients undergoing anterior cervical discectomy (ACD).

Methods

One hundred consecutive patients with 127 levels of cervical disc disease refractory to conservative treatment were randomized into one of the two treatment groups (ICAG/RTC fusion). The visual analog scale was used by the patient to rate overall pain and head, neck, arm, and donor site pain separately. Myelopathy was documented according to Japanese Orthopaedic Association and Nurick grading systems. Outcome was analyzed using Odom criteria, the 36-Item Short Form (SF-36), and Patient Satisfaction Index scales. Fusion rates were assessed on standard and flexion–extension radiographs. Follow-up data of at least 12 months' duration were available for 95 patients.

More residual overall pain after 12 months was documented in patients who underwent ICAG fusion (3.3 ± 2.5 [ICAG] and 2.2 ± 2.4 [RTC]; p < 0.05). Although arm and head pain were minimal in both groups, neck pain proved to be the predominant symptom (2.7 ± 2.5 [ICAG] and 1.9 ± 2.1 [RTC]), which resolved in only 67 and 48% of RTC-and ICAG-treated patients, respectively (p < 0.05). Myelopathy improved comparably in both groups. Regardless of increased pain in ICAG-treated patients, PSI and SF-36 scores were not significantly different between groups (only four [8%] of 47 ICAG-treated patients and five [10%] of 48 RTC-treated patients were unsatisfied). Good to excellent functional recovery according to Odom criteria was observed in 75 and 79% of ICAG- and RTC-treated patients, respectively. Fusion rates were 81 and 74%, respectively (p = 0.51).

Conclusions

Fusion rates and clinical outcome at 12 months after ACD were comparable between patients who underwent ICAG and RTC fusion. The use of rectangular cages, however, avoids donor site morbidity and reduces overall pain and, thus, seems to be an advantageous treatment alternative.

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Peter Vajkoczy, Peter Horn, Claudius Thome, Elke Munch and Peter Schmiedek

Object. The goal of this study was to evaluate regional cerebral blood flow (rCBF) monitoring, performed using thermal-diffusion (TD) flowmetry, as a novel means for the bedside diagnosis of symptomatic vasospasm.

Methods. Fourteen patients with high-grade subarachnoid hemorrhage (SAH) who underwent early clip placement for anterior circulation aneurysms were prospectively entered into the study. Thermal-diffusion microprobes were implanted into the white matter of vascular territories that were deemed at risk for developing symptomatic vasospasm. Data on arterial blood pressure, intracranial pressure, cerebral perfusion pressure, rCBF measurement obtained using a TD probe (TD-rCBF), cerebrovascular resistance (CVR), and blood flow velocities were collected at the patient's bedside. The diagnosis of symptomatic vasospasm was based on the manifestation of a delayed ischemic neurological deficit and/or a reduced territorial level of CBF as assessed using stable Xe-enhanced computerized tomography (CT) scanning in combination with vasospasm demonstrated by angiography.

Bedside monitoring of TD-rCBF and CVR allowed the detection of symptomatic vasospasm. In the 10 patients with vasospasm the TD-rCBF decreased from 21 ± 4 to 9 ± 1 ml/100 g/min (mean ± standard error of the mean), whereas in the four other patients the TD-rCBF value remained unchanged (mean TD-rCBF = 25 ± 4 compared with 21 ± 4 ml/100 g/min). A comparison of the results of TD-rCBF and Xe-enhanced CT studies, as well as the calculation of sensitivities, specificities, predictive values, and likelihood ratios, identified a TD-rCBF value of 15 ml/100 g/min as a reliable cutoff for the diagnosis of symptomatic vasospasm. In addition, TD flowmetry was characterized by a more favorable diagnostic reliability than transcranial Doppler ultrasonography.

Conclusions. Thermal-diffusion flowmetry represents a promising method for the bedside monitoring of patients with SAH to detect symptomatic vasospasm. This is of major clinical interest for patients with high-grade SAH, who often cannot be assessed neurologically.

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Gerrit A. Schubert, Lothar Schilling and Claudius Thomé

Object

Acute cerebral hypoperfusion and early disturbances in cerebral autoregulation after subarachnoid hemorrhage (SAH) have been demonstrated repeatedly and have been shown to contribute significantly to acute and secondary brain injury. Acute vasoconstriction has been identified as a major contributing factor. Although increasing evidence implicates endothelin (ET)–1 in the development of cerebral vasospasm, its role in the acute phase after SAH has not yet been investigated. The purpose of this study was to further determine the role of ET in the first minutes to hours after massive experimental SAH induced by prophylactic treatment with the ET receptor antagonist clazosentan.

Methods

Subarachnoid hemorrhage was induced in 22 anesthetized rats by injection of 0.5-ml arterial, nonheparinized blood into the cisterna magna over the course of 60 seconds. In addition to monitoring intracranial pressure (ICP) and mean arterial blood pressure, laser Doppler flowmetry (LDF) probes were placed stereotactically over the cranial windows to allow online recording of cerebral blood flow (CBF) starting 30 minutes prior to SAH and continuing for 3 hours after SAH. The control group (Group A, 11 rats) received vehicle saline solution via a femoral catheter before SAH, and a second group (Group B, 11 rats) was treated prophylactically with clazosentan, an ETA receptor antagonist. Treatment was started 30 minutes prior to bolus injection (1 mg/kg body weight), immediately followed by a continuous infusion of 1 mg/kg body weight/hr until the end of the experiment.

Results

Induction of SAH in the rats caused an immediate increase in ICP, which led to an acute decrease in cerebral perfusion pressure (CPP). Perfusion, as measured with LDF, was found to have decreased relative to baseline by 30 ±20% in the control group and 20 ±9% in the clazosentan-treated group. Intracranial pressure and CPP recovered comparably in both groups thereafter within minutes. Control animals demonstrated prolonged hypoperfusion with a loss of autoregulation independent of CPP changes, finally approaching 80% of baseline values toward the end of the experiment. The authors observed that clazosentan did not influence peracute CPP-dependent hypoperfusion, but prevented continuous CBF reduction. Laser Doppler flowmetry perfusion readings remained depressed in control animals at 73 ±19% of baseline in comparison with 106 ±25% of baseline in clazosentan-treated animals (p = 0.001).

Conclusions

The first hours after a massive experimental SAH can be characterized by a CPP-independent compromise in cerebral perfusion. Prophylactic treatment with the ET receptor antagonist clazosentan prevented hypoperfusion. It is known that in the first days after SAH, a reduction in CBF correlates clinically to high-grade SAH. Although research currently focuses on delayed vasospasm, administration of vasoactive drugs in the acute phase of SAH may reverse perfusion deficits and improve patient recovery.

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Claudius Thomé, Peter Vajkoczy, Peter Horn, Christian Bauhuf, Ulrich Hübner and Peter Schmiedek

Object. Temporary arterial occlusion (TAO) during aneurysm surgery carries the risk of ischemic sequelae. Because monitoring of regional cerebral blood flow (rCBF) may limit neurological damage, the authors evaluated a novel thermal diffusion (TD) microprobe for use in the continuous and quantitative assessment of rCBF during TAO.

Methods. Following subcortical implantation of the device at a depth of 20 mm in the middle cerebral artery or anterior cerebral artery territory, rCBF was continuously monitored by TD microprobe (TD-rCBF) throughout surgery in 20 patients harboring anterior circulation aneurysms; 46 occlusive episodes were recorded. Postoperative radiographic evidence of new infarction was used as the threshold for failure of occlusion tolerance.

The mean subcortical TD-rCBF decreased from 27.8 ± 8.4 ml/100 g/min at baseline to 13.7 ± 11.1 ml/100 g/min (p < 0.0001) during TAO. The TD microprobe showed an immediate exponential decline of TD-rCBF on clip placement. On average, 50% of the total decrease was reached after 12 seconds, thus rapidly indicating the severity of hypoperfusion. Following clip removal, TD-rCBF returned to baseline levels after an average interval of 32 seconds, and subsequently demonstrated a transient hyperperfusion to 41.4 ± 18.3 ml/100 g/min (p < 0.001). The occurrence of postoperative infarction (15%) and the extent of postischemic hyperperfusion correlated with the depth of occlusion-induced ischemia.

Conclusions. The new TD microprobe provides a sensitive, continuous, and real-time assessment of intraoperative rCBF during TAO. Occlusion-induced ischemia is reliably detected within the 1st minute after clip application. In the future, this may enable the surgeon to alter the surgical strategy early after TAO to prevent ischemic brain injury.

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Mario Cabraja, Michaela Endres, Aldemar A. Hegewald, Samuel Vetterlein, Claudius Thomé, Christian Woiciechowsky and Christian Kaps

Object

Biological repair strategies for the treatment of degenerated intervertebral discs are of growing interest. In addition to the development of nucleus pulposus implants to restore disc height and relieve pain, there is growing demand for an appropriate method for reconstructing the anulus fibrosus (AF). The aim of this pilot study was to evaluate the applicability of a resorbable 3D polymer of pure polyglycolic acid (PGA) combined with hyaluronan for the use in cell-free and cell-based regeneration and repair of the AF.

Methods

Adult human AF cells were expanded in vitro using human serum and rearranged three dimensionally in hyaluronan-PGA scaffolds that were stabilized with fibrin for in vitro analyses. The capacity of dedifferentiated AF cells to redifferentiate was evaluated after 2 weeks of culture, using propidium iodide/fluorescein diacetate staining, gene expression analysis of typical marker genes, and histological staining of proteoglycans.

Results

The propidium iodide/fluorescein diacetate staining demonstrated that vital human AF cells were evenly distributed within the construct. The induction of typical AF marker genes such as collagen Types I–III indicated the initiation of AF redifferentiation by 3D assembly in hyaluronan-PGA. Histological analysis of the constructs showed initial formation of an AF-like matrix comprising proteoglycans.

Conclusions

The results suggest that the 3D arrangement of human AF cells in resorbable hyaluronan-PGA scaffolds cultured in the presence of human serum is an excellent system for AF cell redifferentiation.