Routinely Performed Serial Follow-Up Imaging in Asymptomatic Patients With Multiple Cerebral Cavernous Malformations Has No Influence on Surgical Decision Making

Background: The best strategy to perform follow-up of patients with multiple cerebral cavernous malformations (mCCM) is unclear due to the unpredictable clinical course. Still, serial radiological follow-up is often performed. The objective of this work was to critically question whether active follow-up by serial imaging is justified and has an impact on clinical decision making.Methods: We included all consecutive patients with mCCM treated and followed at our Department between 2006 and 2016. Patient data were collected and analyzed retrospectively.Results: From a total number of 406 patients with CCM, n = 73 [18.0%; mean age at first diagnosis 45.2 years (±2.4 SE); n = 42 male (57.5 %)] were found to harbor multiple lesions (≤5 CCM in 58.9%; 6–25 in 21.9%; ≥ 25 in 19.2%). All of them were followed for a mean of 6.8 years (±0.85 SE). Conservative treatment was suggested in 43 patients over the complete follow-up period. Thirty patients underwent surgical extirpation of at least one CCM lesion. Forty-three surgical procedures were performed in total. During 500.5 follow-up years in total, routinely performed follow-up MRI in asymptomatic patients lead to an indication for surgery in only two occasions and even those two were questionable surgical indications.Conclusion: Routinely performed follow-up MRI in asymptomatic patients with mCCM is highly questionable as there is no evidence for therapeutic relevance

Einfluss von Levetiracetam auf gliale und inflammatorische Komponenten der Epilepsie

Die Beteiligung von Astrozyten bei der Pathogenese von Epilepsie ist kürzlich erkannt worden. Es wurden inflammatorische Effekte in einer $\textit {in-vitro}$ Kokultur (Astrozyten / Mikroglia) provoziert. Die Effekte von LEV (50$\mu$g/ml) wurden auf elektrophysiologische Eigenschaften (durch Ganzzell-Patch-Clamp Elektrophysiologie) und auf die Ausschüttung von TGF-$\beta$1 (durch ELISA) in diesen Kokulturen untersucht. LEV normalisiert das unter inflammatorischen Bedingungen depolarisierte Membranruhepotential durch eine Modifikation der transmembranösen Gleichrichterströme. Ähnliche Effekte werden durch TGF-$\beta$1 vermittelt, welches durch LEV konzentrationsabhängig exprimiert wird. Die Effekte von LEV können durch selektive Antikörperinhibition von TGF-$\beta$1 verhindert werden. Die erhobenen Daten legen nahe, das LEV die schädliche Ausbreitung von pathologischer Exzitation innerhalb des astroglialen funktionellen Synzytiums durch epileptische Aktivität mindert

Posterior open reduction and internal fixation of C1 fractures: the C-clamp technique

Background The treatment of isolated atlas (C1) fractures is still controversial. The surgical management usually involves an arthrodesis of the atlanto-axial (C1-C2) joint with or without occipital fixation. We reviewed the senior author’s series of posterior only open reduction and internal fixation (ORIF) of isolated C1 fractures. Methods Retrospective analysis of consecutive patients with isolated C1 fractures, treated in one institution by posterior only ORIF between 2005 and 2017. All fractures of C1 with concomitant C2 or occipital condyle fractures were excluded. The C1 arch was reduced with C1 lateral mass screws, connected with a transverse rod in a C-clamp fashion. We analyzed neck pain on the visual analog scale (VAS) and imaging signs of instability on follow-up. Results We identified eight patients, six males, and two females with a mean age of 37.9 years (range 20–71 years). All were neurologically intact before surgery, none had a documented transverse ligament disruption, and the mean gap between the fractured pieces was 5.3 mm. Five patients were treated < 72 h of injury, two patients had failed halo vest for 8–10 weeks, and one patient was operated after 6 months because of painful pseudarthrosis despite wearing a hard collar. One patient developed a transient neurological deficit due to vertebral artery dissection that had resolved completely at time of follow-up. The mean follow-up after surgery was 12.6 months (range 1–49 months) and mean preoperative neck pain (VAS 5.1) was significantly decreased (VAS 0.8; p < 0.001). On follow-up radiological evaluation, no instability was noted in any patient. Conclusions Posterior ORIF of C1 fractures may be an option for patients who fail or do not wish to pursue conservative management. The particular advantage of this technique over C1-C2 arthrodesis is the preserved range of rotational motion. Mono-axial screws seem to provide better reduction capacity

Little-known Swiss contributions to the description, diagnosis, and surgery of lumbar disc disease before the Mixter and Barr era

The understanding of lumbar spine pathologies made substantial progress at the turn of the twentieth century. The authors review the original publication of Otto Veraguth in 1929 reporting on the successful resection of a herniated lumbar disc, published exclusively in the German language. His early report is put into the historical context, and its impact on the understanding of pathologies of the intervertebral disc (IVD) is estimated. The Swiss surgeon and Nobel Prize laureate Emil Theodor Kocher was among the first physicians to describe the traumatic rupture of the IVD in 1896. As early as 1909 Oppenheim and Krause published 2 case reports on surgery for a herniated lumbar disc. Goldthwait was the first physician to delineate the etiopathogenes is between annulus rupture, symptoms of sciatica, and neurological signs in his publication of 1911. Further publications by Middleton and Teacher in 1911 and Schmorl in 1929 added to the understanding of lumbar spinal pathologies. In 1929, the Swiss neurologist Veraguth (surgery performed by Hans Brun) and the American neurosurgeon Walter Edward Dandy both published their early experiences with the surgical therapy of a herniated lumbar disc. Veraguth's contribution, however, has not been appreciated internationally to date. The causal relationship between lumbar disc pathology and sciatica remained uncertain for some years to come. The causal relationship was not confirmed until Mixter and Barr's landmark paper in 1934 describing the association of sciatica and lumbar disc herniation, after which the surgical treatment became increasingly popular. Veraguth was among the first physicians to report on the clinical course of a patient with successful resection of a herniated lumbar disc. His observations should be acknowledged in view of the limited experience and literature on this ailment at that time

Residents' learning curve of lumbar transforaminal epidural steroid injections

Background and Study Aims: There is a paucity of literature on beginners' training and on its connection with patient safety for transforaminal epidural steroid injections (TFESIs). This study retrospectively assessed the learning curves and associated complications of neurosurgery residents never previously exposed to TFESI and compared them with experienced board-certified faculty neurosurgeons (BCFNs). Material and Methods Procedure time in minutes, dose-area product (DAP) in cGy*cm(2), periprocedural observations, and complications in 354 TFESIs for radicular pain secondary to lumbar disk herniation or lumbar spinal stenosis were extracted from operative notes and the electronic infiltration logbook in the per-injection format. Learning curves for 238 residents and 116 BCFN TFESIs in terms of procedure time and DAP were estimated using monotone regression. Results Residents' TFESI procedure time and DAP reached BCFN level (4.7 minutes and 140.2 Gy*cm(2)) after 67 and 68 cases, respectively. Residents' TFESIs were unsuccessful in 1.7%, mostly for severe obesity and hypertrophied facet joints, but no severe complications were noted. Obesity, however, did not result in increased procedure times or radiation exposure in general. Residents were faster and required less fluoroscopy in TFESI of the upper lumbar nerve roots than for L5 or S1 in particular. Conclusion The residents' learning curve for TFESIs in terms of procedure time and radiation exposure can be overcome safely after < 70 TFESIs. An outcome analysis correlating to the interventionalist's training level would be worth investigating in future studies

Ten-Day Response to CT-Guided Spinal Infiltration Therapy in More Than a Thousand Patients

BACKGROUND AND STUDY AIMS Infiltration therapy (IT) for degenerative spine disease is considered a valuable nonsurgical treatment option in the absence of severe neurologic deficits. The aim of this study was to evaluate the 10-day response to computed tomography (CT)-guided IT and to identify parameters that are positively or negatively associated with short-term outcome. PATIENTS AND METHODS We conducted a prospective study on 1327 consecutive patients that received CT-guided IT for various spinal disorders between February 2007 and June 2013. Different steroids (betamethasone, dexamethasone, triamcinolone) with or without bupivacaine were applied using different approaches (direct and indirect for cervical nerve roots; transforaminal and interlaminar as well as combined approaches for lumbar nerve roots; facet joint and sacroiliac joint infiltration). The primary end point was the patients' response 10 days after IT, which was graded as better, the same, or worse. The chi-square test was used for subgroup comparisons. RESULTS A total of 1002 patients provided 10-day follow-up. Clinically meaningful pain relief was achieved in 65 of 107 patients treated for cervical disk herniation (60.8%), 27 of 60 for cervical foraminal stenosis (45%), 295 of 412 for lumbar disk herniation (71.6%), 134 of 199 for lumbar spinal stenosis (LSS) (67.3%), 35 of 61 for cervical facet joint pain (57.4%), 87 of 128 for lumbar facet joint pain (68%), and 25 of 35 for sacroiliac joint syndrome (SIJS) (71.4%). There was no difference with regard to the infiltration technique, types, and doses of steroids administered or the add-on of local anesthetics. An age-dependent difference was shown for elderly patients with LSS and SIJS. Repeated infiltrations were equally effective in alleviating pain compared with the first infiltration. CONCLUSIONS CT-guided IT for various spinal disorders has an overall positive response rate of 66.7% after 10 days. Outcome was not unduly influenced by technical variations in technique, types, and doses of steroids administered and probably relates better to the correct indication than to technical aspects

The value of short-term pain relief in predicting the 1-month outcome of 'indirect' cervical epidural steroid injections

BACKGROUND Clinical management after epidural steroid injections (ESI) of patients with radiculopathy secondary to a cervical disc herniation (CDH) is uncertain. This study aims to determine whether short-term arm pain alleviation following computed tomography-guided 'indirect' cervical ESI can predict the 1-month outcome. METHODS We conducted a prospective observation of 45 consecutive patients at a tertiary radiological department. Study components were visual analog scale arm and neck pain at baseline, 15, 30, and 45 min, 1, 2, and 4 h, on days 1-14, 1 month, and at 1 year. Health-related quality of life and functional impairment were assessed using the short form-12 and Neck Pain and Disability Scale. Patients who reported ≥80 % persisting arm pain, as well as patients who underwent a second injection or an operation within 1 month were defined as 'non-responders'. Logistic regression was used to analyze the effect size of the relationship between >50 % pain relief at any given study visit and responder status. RESULTS Patients experiencing a >50 % pain reduction 4 h after the injection were four times as likely to be responders as those experiencing ≤50 % pain reduction (OR 4.04, 95 % CI 1.10-14.87). The effect was strongest on days 5-6 (OR 18.37, 95 % CI 3.39-99.64) and remained significant until day 14. CONCLUSIONS The results of this study can guide physicians in managing patients with CDH: a ≤50 % arm pain relief within 1 week after an 'indirect' cervical ESI predicts an unfavorable 1-month outcome and suggests that other treatment options may be considered at an earlier point in time

The Value of Short-Term Pain Relief in Predicting the Long-term Outcome of Lumbar Transforaminal Epidural Steroid Injections

A previous report demonstrated predictive power of short-term leg pain relief after lumbar transforaminal epidural steroid injections for 1-month treatment response. The question whether the long-term response could be similarly predicted remained unanswered

The value of short-term pain relief in predicting the long-term outcome of 'indirect' cervical epidural steroid injections

BACKGROUND The predictive value of short-term arm pain relief after 'indirect' cervical epidural steroid injection (ESI) for the 1-month treatment response has been previously demonstrated. It remained to be answered whether the long-term response could be estimated by the early post-interventional pain course as well. METHODS Prospective observational study, following a cohort of n = 45 patients for a period of 24 months after 'indirect' ESI for radiculopathy secondary to a single-level cervical disk herniation (CDH). Arm and neck pain on the visual analog scale (VAS), health-related quality of life with the Short Form-12 (SF-12), and functional outcome with the Neck Pain and Disability (NPAD) Scale were assessed. Any additional invasive treatment after a single injection (second injection or surgery) defined treatment outcome as 'non-response'. RESULTS At 24 months, n = 30 (66.7%) patients were responders and n = 15 (33.3%) were non-responders. Non-responders exited the follow-up at 1 month (n = 10), at 3 months (n = 4), and at 6 months (n = 1). No patients were injected again or operated on between the 6- and 24-month follow-up. Patients with favorable treatment response at 24 months had significantly lower VAS arm pain (p  50% short term pain reduction was not a reliable predictor of the 24-month responder status. SF-12 and NPAD scores were better among treatment responders in the long term. CONCLUSIONS Patients who require a second injection or surgery after 'indirect' cervical ESI for a symptomatic CDH do so within the first 6 months. Short-term pain relief cannot reliably predict the long-term outcome