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Aim: To estimate the efficacy of intrathecal treatment with baclofen (ITB) in spasticity and dystonia., Material and Methods: Two groups of patients have been operated: 19 patients with spinal spasticity and 33 patients with cerebral spasticity (cerebral palsy). After baclofen screening test, the Synchromed2 (Medtronic) was implanted. The level of muscle tone was assessed by the Ashworth scale. The locomotion was assessed by GMFM 88 and Arens scale. The dystonia was assessed by the BFM scale. Follow-up was performed 3, 6 and 12 months after the operation and yearly after that. The duration of the follow-up ranged from 2 to 9 years., Results: ITB led to a significant decrease in leg spasticity in both groups of patients (p<0.001). The dynamics of spasticity was more significant in the first group compared to the second group (2.77 and 2.07 points, respectively (p<0.0031)). The dynamics of muscle tone in arms was lesser then in legs (p<0.0022). The positive clinical dynamics in patients with secondary dystonia was minimal (BFM from 65±17 to 60±19). Increasing of ITB daily dose was required to maintenance the clinical effect in most patients. The loss of ITB effect was noted in 5% of patients., Conclusion: ITB was more effective in patients with spinal spasticity. The influence of ITB on the secondary dystonia was lesser then on the spasticity. The dynamic of the muscle tone was more significant in legs than in arms. The loss of ITB effect can be observed in some cases after the operation despite the positive result of baclofen screening-test.

Aim: To analyze complications of intrathecal baclofen therapy and identify high-risk groups., Material and Methods: We implanted 52 pumps to spastic patients for chronic intrathecal baclofen infusion. Two groups of patients were distinguished: 23 patients with spinal spasticity (group 1) and 29 patients with cerebral spasticity (group 2). The mean patient age was 37.2±14.6 years in group 1 and 17.3±10.3 years in group 2. Surgery was performed according to a standard procedure. A Medstream (Codman) pump was implanted in 10 cases, and a Synchromed II (Medtronic) pump was implanted in the remaining 42 cases., Results and Discussion: Complications developed in 12 (23%) patients. We divided complications into 3 groups: baclofen underdose, baclofen overdose, and others. Insufficiency of intrathecal therapy was observed in 7 cases, which was caused by catheter migration (5 cases) and pump dysfunction (2 cases). In one case, baclofen overdose was observed after air travel. Other complications included 4 cases of persistent peri-implant seroma and infectious complications. Groups with a high risk of complications were identified based on an analysis of the results. Patients with severe dystonia of the trunk muscles have an increased risk of spinal catheter migration. Pronounced communicating hydrocephalus is associated with the risk of cerebrospinal fluid leak through a catheter shaft channel. Weakness of the axial musculature can lead to progression of scoliotic deformity., Conclusion: In some cases, chronic intrathecal baclofen therapy can be accompanied by various complications. This technique should be carefully used in patients from high-risk groups.

Objective: To estimate the effectiveness of the chronic intrathecal baclofen infusion (ITB) for the treatment of botuloresistant spastic disorders., Material and Methods: ITB have been performed in 15 cases of spastic disorders. In 8 cases spasticity was the result of cerebral palsy, 5 - spinal cord injure, 1 - cerebral injure, 1 - pyogenic spinal epiduritis. The results of surgical treatment were estimated with the Ashworth, GMFM-88 and Arens scales. These data have been exposed statistically analysis., Results: Significantly decrease of spasticity have been revealed in most cases: from 4.26±0.7 points before the operation to 1.8±0.67 points after the operation (p<0.004). In 8 cases we have observed improvement in motor functions., Conclusion: ITB is an effective procedure which leads to decreasing of spasticity, incree of movement volume and improvement in motor functions in patients with spastic disorders.

Aim: The article is aimed to demonstrate our experience in motor cortex stimulation (MCS) in patients with chronic neuropathic pain syndromes, assess the clinical efficacy of the technique in short-term and long-term follow-up, and analyze potential predictors of the MCS efficacy., Material and Methods: Twenty patients were implanted with MCS electrodes at the Burdenko Neurosurgical Institute in the period between 2004 and 2014. The mean age of patients was 52 years (26 to 74 years). The patients suffered from neuropathic pain syndromes of different genesis (post-stroke, multiple sclerosis, atypical facial pain, phantom limb pain, brachial plexus injury, spinal cord injury, complex regional pain syndrome I). All patients underwent neurological examination with verification of neuropathic pain (DN4, Pain Detect, LANSS). The pain intensity and its effect on quality of life were assessed before operation and during follow-up according to 10-point visual-analog scales (modified Brief Pain Inventory). Before surgery, all patients underwent several repetitive transcranial magnetic stimulation (rTMS) sessions. After implantation of epidural electrodes, test MCS was performed., Results: Test stimulation was positive in 19 (95%) patients. All these patients were implanted with a chronic MCS system. The mean follow-up was 49.3 months (from 3 to 96 months). In short-term follow-up (fist 6 months), a positive result of MCS was observed in 17 patients, and a reduction in the pain intensity ranged from 37.5% to 90%. In long-term follow up (from 12 to 96 months), 14 patients had positive MCS RESULTS: and a reduction in the pain intensity amounted to 25% to 60%. All patients with positive MCS results received significantly decreased doses of opioids and tramadol. Two patients developed infectious complications, but there was no neurological deficit. Analysis of the factors affecting the efficacy of motor cortex stimulation did not reveal a statistically significant effect of rTMS and the presence and intensity of motor deficit., Conclusion: Chronic epidural MCS is an effective and safety method for the treatment of some chronic neurogenic medically-refractory pain syndromes. Further research is necessary to specify the patient selection criteria and the MCS efficacy predictors.

Objectives: The aim of this investigation is to assess the effectiveness of spinal cord stimulation (SCS) in different groups of patients with spasticity of different origin., Materials and Methods: A retrospective study of the use of the method of SCS in 71 patients. The patient population was divided into two groups: 52 cerebral palsy (CP) cases and 19 patients diagnosed with spasticity caused by spinal injury. The mean age was 7.14 ± 4.06 and 35.68 ± 12.42 years, respectively. The CP group included 41 cases of paraparesis and 11 cases tetraparesis. One quadripolar electrode was implanted into the posterior epidural space at Th10-Th12 level and an implantable pulse generator (Itrel3, Medtronic) was placed in a standard fashion. We performed 3-5 stimulation sessions per day; each lasted 30 min. The stimulation parameters were as follows: rate 100-130 Hz, pulse width 120-300 ms, amplitude 1.5-4 V. The follow-up ranged from 2 to 9 years., Results: Decrease in muscle tone was observed in all cases in the group of patients with spinal spasticity: from 3.71 ± 0.61 on the Ashworth scale before the operation to 2.26 ± 0.56 after the operation (p < 0.001). In the group of cerebral spasticity a significant decrease in muscle tone was observed only in patients with spastic lower paraparesis: from 3.36 ± 0.41 before the operation to 1.97 ± 0.91 after the operation (p < 0.005). In patients with spastic tetraparesis we did not observe any significant change in muscle tone. In 8 cases we discontinued the therapy several years after the procedure due to improvement in spasticity: in the CP group in 7 cases and in 1 spinal spasticity case, where SCS systems were explanted., Conclusion: Chronic SCS may be a method of choice for patients with moderate spinal and cerebral spasticity with predominant spastic lower paraparesis. In patients with spastic tetraparesis SCS therapy did not prove to be effective. We encountered improvement of the spasticity and no need for further SCS therapy in a small group of patients (11%). This phenomenon requires further investigation. © 2015 S. Karger AG, Basel.

Aim: Long-term outcomes of selective dorsal rhizotomy (SDR) are not sufficiently summarized in the literature. The aim of this study was to systematize and evaluate long-term outcomes of SDR in various groups of cerebral palsy (CP) patients., Material and Methods: 47 patients with spastic CP were operated. In all cases, SDR of the L1-S1 roots was performed under EMG control. In all cases, laminoplasty was used as an approach. Outcomes of surgical treatment were estimated by the Ashworth scale and the GMFM 88 scale. The data were subjected to statistical analysis. The follow-up duration ranged from 12 months to 7 years., Results: A significant reduction in spasticity from 4.34±0.53 points before surgery to 1.61±0.45 points after surgery (p<0.001) was observed in most cases. The dynamics of locomotor functions was maximal in the 3rd GMFM class: changing from 48±4% points before operation to 52±6% points 12 months after operation (p<0.042). The dynamics of locomotor functions amounted to 2% in the 4th GMFM class and 1% in the 5th GMFM class. The best functional outcomes were obtained in children under 10 years of age. A positive correlation only between the percentage of cut roots and a decrease in spasticity (r= 0.85) was found. No correlation between the amount of cut roots and the dynamics of locomotor functions was observed. No spinal cord deformities were observed during the follow-up period., Conclusion: A reduction in spasticity due to SDR depends on the amount of cut roots. The functional result of SDR is affected not only by a decrease in spasticity but also by the functional status and age of the patient at the time of surgery. In all cases, laminoplasty should be performed to prevent spinal cord deformities.

Object: To estimate the effectiveness of selective peripheral neurotomy (SPN) in the treatment of local botuloresistant spastic disorders., Methods: 20 SPNs were performed in 18 patients with spastic disorders. In 11 cases we performed SPN of the nervus obturatorius, in 5 - tibialis, in 3 - musculocutaneous, in 1 - radialis. The results of surgical treatment were estimated by the Ashworth scale and GMFM-88. These data was statistically processed., Results: There was a significant decrease of spasticity in most cases: from 4,02±0,52 points before surgery to 1,86±0,63 points after surgery (p<0,001). In 11 cases we observed significant improvement in motor functions: from 50,7±12,92% before surgery to 54,9±13,6% after surgery (p<0,001)., Conclusion: SPN is an effective procedure which leads to significant reduction of spasticity, improvement in movement range motor functions in patients with spastic disorders.

The article presents the description of clinical observation, in which spinal neurosurgical intervention was successfully made in a patient with ESRD, receiving chronic hemodialysis for 20 years. In this context, we discuss the various clinical and tactical aspects of the management of patients with this severe co-pathology: infusion-transfussion therapy, peculiarities of anesthetic management and intra-operation monitoring, diagnostics and correction of hemostasis disorders, hemodialysis organization.

The study reports the results of monitoring the depth of anesthesia with BIS technology in 456 neurosurgical patients with different neurosurgical pathology: sub- and supratentorial tumors, aneurisms, arteriovenous malformations, spinal pathology, etc. BIS reflects hypnotic state of the brain during anesthesia in almost all the cases, except for bifon-tal surgical approach when sensor placement is impossible. BIS monitoring of the depth of anesthesia is most advantageous in the following cases: epilepsy surgery, spine surgery with neurophysiological monitoring, awake craniotomy, severe cardiovascular pathology, massive blood loss, neurosurgery in pregnant patients.

The analysis of the results of bilateral monitoring of the depth of anesthesia in 22 patients with neurosurgical pathology of the posterior cranial fossa using the technique bispectral index (BIS). The results showed that more than half of the observations (at 19 and 22 patients) during the main phase of the operation (removal of the tumor) were observed differences in the BIS index values between the right and left side. In 1/3 of patients, these differences were driven by higher values of BIS on the side of surgery. By the end of removal of the tumor and, particularly, by the end of surgery there was a complete alignment of values of the BIS on the right and left.

The paper describes an unusual clinical case. During a neurosurgical operation (removal of parastem tumor (neuroma) on the right side), bilateral registration of the bispectal index (BSI) in order to monitor a hypnotic component of anesthesia showed that the tumor removal stage was marked by a paradoxical reaction of the BSI as an increase in its values up to 70-80% (corresponds to the patient's emergence) on the right, ipsilaterally, with the preserved low BSI values on the left--30-40%. Possible explanations of the observed are considered.

Background: Aim of this study was to optimize surgical technique of posterior selective rhizotomy for prevention of possible complications., Materials and Methods: 11 patients (age 3-30 years) with severe spastic tetraparesis due to cerebral palsy were operated. Muscle tone in lower limbs reached 4-5 points (Ashworth scale). In all cases posterior selective rhizotomy of L1-S1 spinal roots was performed using laminoplasty and intraoperative electromyographic monitoring. Results were assessed in early postoperative period and during follow-up., Results: In all cases in the early postoperative period we observed decrease of muscle tone to 1-2 points and increase of volume of passive movements. In the follow-up period 4 patients developed improvement of locomotor status, in 6 no changes were observed. In 1 case spastic syndrome recurred. We had no complications due to orthopaedic deformities of spinal column, sensory and pelvic disorders, muscular hypotonia., Conclusion: Posterior selective rhizotomy may be the method of choice in treatment of patients with severe spastic forms of cerebral palsy. Application of optimized surgical technique (laminoplasty, intraoperative stimulation electromyography) allows to decrease the risk of possible complications.

The literature contains rare reports on anesthetic maintenance in non-cardiac operations in patients with dilated cardiomyopathy and an ejection fraction of less than 30%. Life-saving non-cardiosurgical interventions are performed in these patients since they are associated with a high risk for perioperative complications and fatal outcome. In these cases, anesthetic maintenance is performed with inotropic support; there is frequently a need to use a pacemaker, a cardioverter, or a LV assist device. The paper describes the first case of xenon anesthesia in a patient with dilated cardiomyopathy with an ejection fraction of less than 30% and rapidly progressing spinal cord tumor. The ability of xenon to maintain stable blood pressure and cardiac contractility could prevent perioperative infusion of inotropic agents. In 60-70% of cases, the maximum alveolar concentration of xenon enables anesthesia to be virtually performed as monoanesthesia without adding the anesthetics lowering cardiac contractility; the low blood-gas distribution coefficient ensures early emergence from anesthesia with early extubation and activation of a patient. In the author's opinion, xenon anesthesia has every reason to become the method of choice as anesthetic maintenance in patients with severe cardiac dysfunction.