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Daniel Rosenthal, Gerhard Marquardt, Ruediger Lorenz and Michael Nichtweiß

✓ It is well accepted that the treatment of spinal tumors that threaten neurological integrity comprises resection, vertebral body reconstruction, and stabilization if the patient's condition is suitable. In spite of the excellent results reported using thoracotomy, the majority of investigators recommend posterolateral techniques because of lower morbidity, shorter hospitalization time, and the possibility of performing dorsal stabilization via the same incision. To overcome some of the disadvantages of thoracotomy, the authors developed an anterior procedure that permits vertebrectomy, reconstruction, and stabilization to be performed entirely by endoscopic technique. Microsurgical endoscopy and stabilization were performed in four patients with metastatic disease of the thoracic spine. All were ambulatory after surgery and at follow up; preoperative neurological and neurophysiological deficits improved as well. No complications occurred in this small series. Microsurgical endoscopy achieves a substantial reduction in trauma, use of analgesic medications, and hospitalization time. Early results seem to indicate that adequate decompression, stabilization and reduction of surgical morbidity can be achieved with this technique.

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Seba Ramhmdani and Ali Bydon

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Stephan Dützmann, Florian Geßler, Gerhard Marquardt, Volker Seifert and Christian Senft

Object

The authors performed a study to evaluate whether preoperative assessment of prothrombin time (PT) is mandatory in patients undergoing routinely planned neurosurgical procedures.

Methods

The charts of all patients admitted to general wards of the authors' department for routinely planned surgery (excluding trauma and ICU patients) between 2006 and 2010 were retrospectively reviewed. The authors assessed preoperative PT and the clinical courses of all patients, with special consideration for patients receiving coagulation factor substitution. All cases involving hemorrhagic complications were analyzed in detail with regard to pre- and postoperative PT abnormalities. Prothrombin time was expressed as the international normalized ratio, and values greater than 1.28 were regarded as elevated.

Results

Clinical courses and PT values of 4310 patients were reviewed. Of these, 33 patients (0.7%) suffered hemorrhagic complications requiring repeat surgery. Thirty-one patients (94%) had a normal PT before the initial operation, while 2 patients had slightly elevated PT values of 1.33 and 1.65, which were anticipated based on the patient's history. In the latter 2 cases, surgery was performed without prior correction of PT. Preoperatively, PT was elevated in 78 patients (1.8%). In 73 (93.6%) of the 78 patients, the PT elevation was expected and explained by each patient's medical history. In only 5 (0.1%) of 4310 patients did we find an unexpected PT elevation (mean 1.53, range 1.37–1.74). All 5 patients underwent surgery without complications, while 2 had received coagulation factor substitution preoperatively, as requested by the surgeon, because of an estimated risk of bleeding complications. None of the 5 patients received coagulation factor substitution postoperatively, and later detailed laboratory studies ruled out single coagulation factor deficiencies. There was no statistically significant association between preoperatively elevated PT levels and the occurrence of hemorrhagic complications (p = 0.12). Before the second procedure but not before the initial operation, 4 (12%) of the 33 patients had elevated PT.

Conclusions

The findings suggest that the value of preoperative PT testing is limited in patients in whom a normal history can be ascertained. Close postoperative PT control is necessary in every neurosurgical patient, and better tests need to be developed to identify patients who are prone to hemorrhagic complications.

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Markus Bruder, Adriano Cattani, Florian Gessler, Christian Droste, Matthias Setzer, Volker Seifert and Gerhard Marquardt

OBJECTIVE

Synovial cysts of the spine are rare lesions, predominantly arising in the lumbar region. Despite their generally benign behavior, they can cause severe symptoms due to compression of neural structures in the spinal canal. Treatment strategies are still a matter of discussion. The authors performed a single-center survey and literature search focusing on long-term results after minimally invasive surgery.

METHODS

A total of 141 consecutive patients treated for synovial cysts of the lumbar spine between 1997 and 2014 in the authors’ department were analyzed. Medical reports with regard to signs and symptoms, operative findings, complications, and short-term outcome were reviewed. Assessment of long-term outcome was performed with a standardized telephone questionnaire based on the Oswestry Disability Index (ODI). Furthermore, patients were questioned about persisting pain, symptoms, and further operative procedures, if any. Subjective satisfaction was classified as excellent, good, fair, or poor based on the Macnab classification.

RESULTS

The approach most often used for synovial cyst treatment was partial hemilaminectomy in 70%; hemilaminectomy was necessary in 27%. At short-term follow-up, the presence of severe and moderate leg pain had decreased from 93% to 5%. The presence of low-back pain decreased from 90% to 5%. Rates of motor and sensory deficits were reduced from 40% to 14% and from 45% to 6%, respectively. The follow-up rate was 58%, and the mean follow-up period was 9.3 years. Both leg pain and low-back pain were still absent in 78%. Outcome based on the Macnab classification was excellent in 80%, good in 14%, fair in 1%, and poor in 5%. According to the ODI, 78% of patients had no or only minimal disability, 16% had moderate disability, and 6% had severe disability at the time of follow-up. In this cohort, 7% needed surgery due to cyst recurrence, and 9% required a delayed stabilization procedure after the initial operation.

CONCLUSIONS

Surgical treatment with resection of the cyst provides favorable results in outcome. Excellent or good outcome persisting for a long-term follow-up period can be achieved in the vast majority of cases. Complication rates are low despite an increased risk of dural injury. With facet-sparing techniques, the stability of the segment can be preserved, and resection of spinal synovial cysts does not necessarily require segmental fusion.

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Juergen Konczalla, Volker Seifert, Juergen Beck, Erdem Güresir, Hartmut Vatter, Andreas Raabe and Gerhard Marquardt

OBJECTIVE

Outcome analysis of comatose patients (Hunt and Hess Grade V) after subarachnoid hemorrhage (SAH) is still lacking. The aims of this study were to analyze the outcome of Hunt and Hess Grade V SAH and to compare outcomes in the current period with those of the pre–International Subarachnoid Aneurysm Trial (ISAT) era as well as with published data from trials of decompressive craniectomy (DC) for middle cerebral artery (MCA) infarction.

METHODS

The authors analyzed cases of Hunt and Hess Grade V SAH from 1980–1995 (referred to in this study as the earlier period) and 2005–2014 (current period) and compared the results for the 2 periods. The outcomes of 257 cases were analyzed and stratified on the basis of modified Rankin Scale (mRS) scores obtained 6 months after SAH. Outcomes were dichotomized as favorable (mRS score of 0–2) or unfavorable (mRS score of 3–6). Data and number needed to treat (NNT) were also compared with the results of decompressive craniectomy (DC) trials for middle cerebral artery (MCA) infarctions.

RESULTS

Early aneurysm treatment within 72 hours occurred significantly more often in the current period (in 67% of cases vs 22% in earlier period). In the earlier period, patients had a significantly higher 30-day mortality rate (83% vs 39% in the current period) and 6-month mortality rate (94% vs 49%), and no patient (0%) had a favorable outcome, compared with 23% overall in the current period (p < 0.01, OR 32), or 29.5% of patients whose aneurysms were treated (p < 0.01, OR 219). Cerebral infarctions occurred in up to 65% of the treated patients in the current period.

Comparison with data from DC MCA trials showed that the NNTs were significantly lower in the current period with 2 for survival and 3 for mRS score of 0–3 (vs 3 and 7, respectively, for the DC MCA trials).

CONCLUSIONS

Early and aggressive treatment resulted in a significant improvement in survival rate (NNT = 2) and favorable outcome (NNT = 3 for mRS score of 0–3) for comatose patients with Hunt and Hess Grade V SAH compared with the earlier period. Independent predictors for favorable outcome were younger age and bilateral intact corneal reflexes. Despite a high rate of cerebral infarction (65%) in the current period, 29.5% of the patients who received treatment for their aneurysms during the current era (2005–2014) had a favorable outcome. However, careful individual decision making is essential in these cases.

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Gerhard Marquardt, Soledad M. Barduzal Angles, Fouad D. Leheta and Volker Seifert

✓ A rare case of peripheral-nerve compression in the upper arm caused by a spontaneous venous aneurysm is reported. The apparent dysfunction of the median nerve led to various vain surgical explorations of the nerve at different levels. The real localization of nerve entrapment was identified by a thorough clinical examination, and sonography yielded a correct diagnosis. Surgical resection of the venous aneurysm resulted in complete relief of pain. To the authors' knowledge, this is the first report of a spontaneous venous malformation in the upper arm causing focal neuropathy.

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Acute posttraumatic spinal cord herniation

Case report and review of the literature

Gerhard Marquardt, Stefan Weidauer, Friedhelm E. Zanella and Volker Seifert

✓ Transdural herniations of the spinal cord are rare, and those occurring acutely after a spinal cord injury (SCI) are particularly unusual. In this report, the authors present the case of acute posttraumatic spinal cord herniation in a patient who sustained severe polytraumatic injuries. The clinical manifestations were acute flaccid paralysis of the right leg and rapidly progressive sensorimotor deficits of the contralateral leg. The herniation was surgically reduced. Postoperatively left leg paralysis was completely resolved. The authors review the pertinent literature, and suggest that, with regard to another underlying pathophysiological mechanism, cases of acute posttraumatic spinal cord herniation should be differentiated from those “posttraumatic” cases in which herniation of the spinal cord occurs years or even decades after the traumatic event. To the best of the authors' knowledge, only one similar case has been previously reported. They conclude that acute posttraumatic spinal cord herniation should be included in the differential diagnosis of acute neurological deterioration after SCI.

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Matthias Setzer, Hartmut Vatter, Gerhard Marquardt, Volker Seifert and Frank D. Vrionis

Object

In this report, the authors describe their experience in the surgical management of spinal meningiomas at two neurosurgical centers. The results of a literature review are also presented.

Methods

Eighty consecutive patients (22 men and 58 women) with spinal meningiomas who had undergone an operation at two specific neurosurgical centers were included in this study. Functional outcomes were evaluated using univariate and multivariate analyses. A review of the literature yielded an additional 651 patients with spinal meningiomas from 9 large studies.

Results

On multivariate analysis, the variable of a poor preoperative neurological state (p < 0.02, odds ratio [OR] 13.6, 95% confidence interval [CI] 2.6–71.4) and invasion of the arachnoid/pia mater (p < 0.03, OR 15.2, 95% CI 2.5–90.4) were independent predictors of a poor outcome, whereas invasion of the arachnoid/pia (p < 0.02, OR 8.9, 95% CI 2.2–35) and duration of symptoms (p < 0.001, OR 1.12/month, 95% CI 1.05–1.2) predicted no improvement (stable or deteriorated condition). The Cox proportional hazards regression analysis showed three significant predictor variables for recurrence: invasion of the arachnoid/pia (p < 0.05; hazard ratio [HR] 1.8, 95% CI 1.2–3.6), Simpson resection grade (p < 0.012, HR 6.8, 95% CI 1.5–3.0), and histological tumor grade (Grade I; p < 0.001, HR 0.001–0.17).

Conclusions

Because of the excellent outcome of surgery for benign spinal meningiomas and the association between duration of symptoms and neurological compromise with a poor functional outcome, early operation is the treatment of choice. In cases of malignant transformation, adjuvant therapies must be considered.

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Rüdiger Gerlach, Gerhard Marquardt, Heimo Wissing, Inge Scharrer, Andreas Raabe and Volker Seifert

✓ The authors report on a 64-year-old woman with a huge recurrent skull base hemangiopericytoma, in whom they encountered severe difficulty in attaining intraoperative hemostasis. Standard surgical hemostatic methods and the administration of fresh-frozen plasma and prothrombin complex concentrates failed to stop diffuse bleeding from an inoperable tumor remnant. At a critical point during the operation, the intravenous administration of recombinant activated factor VII, combined with mechanical compression, finally led to satisfactory hemostasis. The rationale for using recombinant activated factor VII in situations of uncontrolled bleeding during neurosurgical procedures is discussed, along with the literature in which the use of recombinant activated factor VII as a maneuver of last resort is reported for hemostasis in other surgical fields.