✓The authors describe the unusual case of a 50-year-old woman who suffered from sciatic pain due to periligamentous trapped epidural gas after lumbar sequestrectomy. The patient underwent removal of free herniated disc material via a translaminar approach through the L-5 lamina without discectomy. Four days later she suffered from recurrent pain, and neuroimaging studies revealed an epidural gas formation at the site of the sequestrectomy. After evacuation of the gas, her pain resolved. Postoperative intraspinal gas may be symptomatic in the rare case.
Hans-Holger Capelle and Joachim K. Krauss
Joachim K. Krauss and Fritz Mundinger
✓ The symptomatic and functional outcomes of a series of 14 patients with disabling and medically refractory hemiballism who were treated with functional stereotactic surgery are reported. Seven (50%) of the 14 patients had concomitant hemichorea. To relieve the hyperkinesia, the 14 patients underwent a total of 15 stereotactic operations (one patient had a second stereotactic procedure). Combined lesions in the contralateral zona incerta and the base of the ventrolateral (oroventral) thalamus were applied in 13 instances. The zona incerta was reached by means of a movable chord electrode to obviate the need for repeated puncture. In two instances the medial pallidum was used as the stereotactic target. Hemiballism was abolished or considerably improved in 13 (93%) of 14 patients in the immediate postoperative phase. Residual dyskinesia was evaluated using the hemiballism/hemichorea outcome rating scale. Long-term follow-up review was available for 13 of the 14 patients (mean follow-up period 11 years). Persistent improvement in the hemiballism was found in 12 of these 13 patients: seven patients (54%) were free of any hyperkinesia and five patients (39%) had minor residual and predominantly hemichoreic hyperkinesia. One of the 13 patients presented with a probable psychogenic movement disorder at long-term follow-up examination. Persistent morbidity, most likely related to the operative intervention, was detected in three of the 13 patients; this included mild hemiparesis and dystonia. Functional disability was assessed using the Huntington's Disease Activities of Daily Living scale. The patients' preoperative mean value of 83% of maximum disability was reduced to a mean of 30% observed at long-term follow-up review (p < 0.001). The residual disability exhibited in most older patients was associated with cardiovascular disease. The authors compare their findings with the results of 44 cases reported previously. The authors contend that functional stereotactic surgery should be considered in patients with persistent, medically refractory hemiballism.
Dimitris Zevgaridis, Claudius Thomé, and Joachim K. Krauss
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.
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.
The authors conclude that the use of titanium cages in anterior cervical discectomy constitutes a safe and efficient alternative to iliac crest bone autograft.
Ralf Weigel, Michael Rittmann, and Joachim K. Krauss
✓ The authors report on a 31-year-old man with spontaneous craniocervical osseous fusion secondary to cervical dystonia (CD). After an 8-year history of severe CD, the patient developed a fixed rotation of his head to the right. Three-dimensional computerized tomography reconstructions revealed rotation and fixation of the occiput and C-1 relative to C-2, which was similar to that seen in atlantoaxial rotatory fixation. There was abnormal ossification of the odontoid facet joints and ligaments. Additional ossification was observed in the cervical soft tissue bridging the lateral mass of C-1 and the occiput. The patient underwent partial myectomy of the dystonic left sternocleidomastoid muscle and selective posterior ramisectomy of the right posterior neck muscles; postoperatively he experienced relief of his neck pain. In patients with CD refractory to conservative treatment, the appropriate timing of surgical treatment is important.
Thomas M. Kinfe, Hans-Holger Capelle, and Joachim K. Krauss
The object of this study was to investigate the impact of surgical treatment on tremor caused by posterior fossa tumors.
The authors performed a retrospective evaluation of 6 cases involving patients with tremors due to posterior fossa tumors. Patients who had been treated with neuroleptic medication or had a family history of movement disorders were excluded. All patients had postural or kinetic tremors. Tremor was mainly unilateral. The study group included 5 women and 1 man. Mean age at surgery was 59 years. Five patients underwent total or subtotal tumor resection, and 1 patient underwent stereotactic biopsy only. The histological diagnosis was epidermoid tumor in 2 patients, metastasis in 2 others, and vestibular schwannoma and low-grade glioma in 1 each.
Two patients had no improvement of tremor, postoperatively. In both of these patients the tumor (low-grade glioma in 1, metastasis in the other) involved the dentate nucleus directly. In the other patients, a compressive effect on the dentate nucleus or the dentatothalamic pathways was present without invasion of the cerebellar structures, and immediate or gradual amelioration of the tremor was observed postoperatively.
The prognosis of tremor due to posterior fossa tumors appears to depend mainly on the involvement of tremor-generating structures. The prognosis appears to be favorable in those patients with compression of these substrates, whereas primary invasion by tumor has a poor prognosis. Caution must be used in generalizing the findings of this study because of the small number of cases in the series.
Joachim K. Krauss, Remo Koller, and Jean-Marc Burgunder
✓ The authors describe a technique for performing partial sectioning and myectomy of the trapezius muscle in patients with severe cervical dystonia that is unresponsive to conservative treatment. Asleep-awake-asleep anesthesia allows intraoperative control of the sectioning procedure to avoid causing postoperative weakness of arm elevation above the horizontal plane. The procedure has been performed successfully in three patients. In all cases the dystonic posture of the shoulder and local pain were improved postoperatively. There were no new deficits. This technique can be used as an adjunct to other peripheral surgical procedures in patients with marked laterocollis and dystonic elevation and anteversion of the shoulder.
Kazem Ghaemi, Joachim K. Krauss, and Makoto Nakamura
Cavernous angiomas of the upper brainstem causing hemiparkinsonism are very rare. Due to their difficult-to-reach localization, brainstem cavernomas, in particular those in anterior locations, continue to present a therapeutic challenge.
The authors report on a 16-year-old boy with a pontomesencephalic cavernoma who developed hemiparkinsonism and hemiparesis after hemorrhage. After complete surgical removal of the pontomesencephalic cavernoma via a pterional transsylvian approach, his symptoms resolved.
Although pontomesencephalic cavernomas occupying the ventral portion of the brainstem are regarded as problematic for resection, the pterional transsylvian approach provides an excellent route for removal of cavernomas that are in contact with the ventral surface of the midbrain in the interpeduncular cistern. Surgical removal of this type of lesion is recommended because resolution of clinical symptoms, including hemiparkinsonism, can be achieved.
Hans-Holger Capelle, Thomas M. Kinfe, and Joachim K. Krauss
Hemichorea-hemiballism is a rare movement disorder that has various causes. In treatment-resistant cases, both thalamic and pallidal functional procedures have been shown to yield beneficial results. Until now it has not been clarified whether the thalamus or the pallidum would yield a superior outcome.
After resection of a craniopharyngioma in this patient at the age of 49 years, hemichorea-hemiballism developed, with a latency of several weeks. Because the patient was greatly impaired by the movement disorder, she underwent implantation of deep brain stimulation (DBS) electrodes in the thalamic ventralis intermedius nucleus and the posteroventral lateral globus pallidus internus. Although both pallidal and thalamic stimulation could suppress the movement disorder, the voltage needed was clearly less with thalamic than with pallidal stimulation. At the last available follow-up 25 months postoperatively, complete subsidence of hemichorea-hemiballism was achieved with long-term thalamic stimulation.
Long-term DBS therapy is an efficient treatment modality for refractory hemichorea-hemiballism in the long run (> 2 years). A bifocal (thalamic and pallidal) target paradigm allowed selection of the optimal stimulation site. Thalamic DBS was more favorable with regard to energy consumption.
Ralf Weigel, Hans-Holger Capelle, and Joachim K. Krauss
Stimulation of dorsal nerve roots or dorsal root ganglia was reported to alleviate neuropathic pain in selected patients during the early postoperative period. A prospective study was initiated to investigate long-term outcome in patients with neuropathic pain of the lower extremities or groin who were treated with selective nerve root stimulation.
The study included patients with dermatomally distributed neuropathic pain who were > 18 years of age and in whom the pain was refractory to medical treatment. The patients were prospectively evaluated using a visual analog scale (VAS) for pain and ratings for quality of life, activities of daily living, and depression preoperatively, and after defined intervals postoperatively. Implantation of electrodes was performed via foraminotomy or interlaminar fenestration in an awake procedure. An implantable pulse generator (IPG) was implanted in a second operation after successful test stimulation performed over several days.
Three patients were included in the study before it was stopped. The mean maximum pain score preoperatively was 9.3. All patients had successful test stimulation with > 50% pain relief prior to implantation of the IPG (mean maximum VAS Score 3.6). The beneficial effect, however, was lost within the next few months despite adjustment of stimulation settings. With higher amplitudes, side effects such as pain attacks or motor phenomena occurred. They disappeared after stopping stimulation, but neuropathic pain recurred to its full extent. The study was stopped 18 months after the first implantation, when the third and last IPG of this series was explanted. Due to the overall short-term effect of stimulation, no relevant changes in ratings for quality of life, activities of daily living, or depression were detected.
Spinal nerve root stimulation proved to be effective on short-term follow-up in 3 patients with neuropathic pain in a dermatomal distribution. Long-term stimulation, however, was disappointing because of the loss of effectiveness and the occurrence of side effects.