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The epidural haematoma (EDH) is a potentially life-threatening complication after severe traumatic brain injury (TBI). However, it also occurs after mild or moderate TBI. The EDH is characterized by a variable clinical presentation in the acute situation. If undetected and untreated the EDH may lead to progressive transtentorial herniation with loss of consciousness, pupillary dilation, and further neurologic deficits. Native CT-scanning remains the diagnostic gold standard in the emergency scenario. When an EDH is identified, an emergency craniotomy is indicated according to the clinical and radiological presentation. The clinical outcome depends on the time of treatment. Below, clinical presentation, diagnosis and relevant treatment modalities of the EDH are discussed.

The classic cervicobrachialgia results acutely from cervical nerve root compression by disc herniation or subacutely by radicular compression after progressive spondylotic changes of the cervical spine. The clinical presentation includes local and radiating pain syndromes that can be accompanied by sensorimotor deficits. Besides the medical history and a targeted clinical examination, supplementary radiographic means should be undertaken to confirm diagnosis. If no urgent surgical indication exists, conservative therapy should be initiated. However, with varying results of conservative and surgical therapy, chronic impairment can occur.

Lumbar disc herniation has a high prevalence and strong social-medical impact. Patients suffer from lower back pain that radiates from the spine. Loss of sensation or paresis adds to the clinical picture. The diagnosis should be confirmed by imaging in patients considered for surgery. High remission rates initially warrant conservative treatment (adequate analgesia and physiotherapy) in many patients. If this treatment does not lead to significant alleviation within 5-8 weeks, surgery should be performed to reduce the risk of chronic nerve affection. Posterior interlaminar fenestration is the intervention primarily conducted for this diagnosis. A relapse in the same region occurs in up to 10% of patients after months through years, which sometimes necessitates a reoperation if symptoms are pertinent.

Cerebral arteriovenous malformations (AVM) are vascular lesions that occur either congenitally or arise in early childhood. AVM are characterised by arteriovenous shunts through a nidus of coiled and tortuous vascular connections that connect feeding arteries to draining veins. Generally, AVM become evident through intracranial haemorrhage in patients aged 20-40 years. Especially, in the young adult presenting with epileptic seizures or focal neurological deficits AVM needs to be considered as an important differential diagnosis. Treatment modalities for the occlusion of symptomatic AVM include microneurosurgery, endovascular embolisation, or radiosurgery. These can be performed each on its own or in combination with the others. Incidentally diagnosed AVM require a thorough and individual consideration of treatment indications. This review deals with the current recommendations for the treatment of AVM in the adult patient.

Intracerebral haemorrhages (ICH) are responsible for 10-17% of all strokes and are associated with a high mortality and morbidity. More than 50% of the primary cases of ICH are associated with an underlying arterial hypertension and up to 30% with a cerebral amyloidosis. In supratentorial ICH, primary treatment generally should be conservative, as clinical studies could not show favourable outcomes after surgical haematoma evacuation. However, in patients with infratentorial haemorrhages and neurologic deterioration, early surgical evacuation should be considered. Modern therapeutic strategies and the focus of current and recent clinical research include early haemostasis, improvement of intensive care, and less invasive neurosurgical interventions, with the aim to reduce secondary brain damage. This review provides an overview of the clinical presentation of ICH and includes up-to-date recommendations concerning diagnostic and therapeutic options.

Intradural spinal tumors are classified in extra- and intramedullary tumors. The most frequent intradural-extramedullary tumors are meningiomas and neurinomas. Among the intradural-intramedullary tumors the most frequent ones are ependymomas and astrocytomas. Independent of their origin, spinal tumors usually manifest with progressive local or radicular pain and neurological deficits. The treatment of choice for most of these tumors is a complete surgical resection. In tumors with infiltrative growth into the intramedullary area, a marginal tumor tissue has to be left in situ in order to avoid additional neurological deficits. In particular if neurological deficits appear, a fast surgical intervention is indicated, since the prognosis depends on duration and severity of the preoperative existing deficits. Below, clinical presentation and relevant treatment options of spinal intradural tumors are discussed.

Spinal tumors are classified according to their location in extradural, intradural-extramedullary, and intradural-intramedullary tumors. The most frequent extradural tumors are metastases. Primary spinal tumors are rare and predominantly benign. Independent of their origin, spinal tumors manifest themselves with progressive local or radicular pain and neurological deficits. A preferably early diagnosis and subsequent therapy is important to improve the prognosis. The treatment of choice for most of these tumors is the complete surgical resection. In particular with the occurrence of neurological deficits a fast surgical intervention is indicated, since the prognosis depends on duration and severity of the preoperative existing deficits. Below, clinical presentation and relevant treatment options of spinal extradural tumors are discussed.

Syringomyelia describes an intra-medullary cyst in the spinal cord. In the adult patient, the pathology mostly results from Chiari-I-malformation or from severe spinal trauma. The clinical picture varies broadly, but symptoms often include pain and progressive neurologic deficits. During the clinical course, muscular atrophy and loss of pain and temperature sensation may develop in the affected region. Today, magnet resonance imaging helps to detect syringomyelia at an early stage. The interdisciplinary therapeutic approach includes an adequate pain treatment and physiotherapy, in selected cases a surgical intervention by an experienced surgeon. If not treated surgically, most symptomatic patients experience progressive neurologic deficits that may lead to severe paragplegia and chronic neuropathic pain.

A 58-year-old female admitted herself to the emergency department with progressive left-sided facial hypoesthesia. Magnetic resonance imaging revealed a 20 mm-sized aneurysm of the left vertebral artery leading to compression of the trigeminal nerve. An endovascular occlusion with a combined coiling and flow-diverter was performed. The left posterior inferior cerebellar artery (PICA) arised from the aneurysmal sac. Despite an extensive infarction of the left PICA-territory, the patient convalesced well and presented completely independent and without symptoms at the 4-week follow-up.

Deep brain stimulation (DBS) is meanwhile an established procedure. It has been employed for several neurological diseases with impressive therapeutic responses to some extent. Stimulation of the ventral intermediate nucleus of the thalamus can distinctively improve tremor associated with essential tremor or Parkinson disease. Similarly, stimulation of the subthalamic nucleus or the globus pallidus internus can substantially diminish bradykinesia, rigidity, and tremor. Additionally, by means of a reduced dopaminergic therapy, it can lead to an improvement of the L-Dopa induced dyskinesias in patients with Parkinson disease. In recent years, DBS has also been used for other neurological and psychiatric diseases. Yet, the exact mechanism of action on a neuronal level remains uncertain. Regardless of the underlying disease and the surgical electrode positioning, a meticulous patient selection and correct indication is of paramount importance for the therapeutic success.

Meningiomas are common intracranial tumours that arise from arachnoidal cells. Clinically they often manifest by headache, focal or generalized seizures, or neurologic deficits as a result of brain compression. More than 90 percent of these mostly slow growing meningiomas are benign. In symptomatic patients a resection should be performed with the intention to cure or at least alleviate symptoms. In cases of subtotal resection an adjuvant radiotherapy should be deliberated. Stereotactic radiotherapy as initial treatment is an effective alternative for meningiomas, especially in patients not suitable for surgery due to various reasons. In patients that are refractory to treatment or with unresectable disease a hormonal- or chemotherapy can be considered.

Subdural hematomas (SDH) are associated with an increased morbidity and mortality and generally occur as chronic SDH among older patients. The most frequent signs and symptoms - like headache, alteration of consciousness, gait impairment and hemiparesis - are also prevalent among other diseases, which has to be taken into account in the differential diagnosis. In the case of symptomatic patients with focal neurological deficits, a surgical intervention should be considered, whereas in case of asymptomatic patients or patients with only slight headaches, also a conservative treatment with a clinical and radiological follow-up might be a possibility. Also after surgical intervention, the recurrence rate is between 5 and 33%. Therefore, all patients with chronic SDH depict, irrespective of the indication for an oral anticoagulation, a challenge for the treating physicians.

The most characteristic symptom of an aneurysmal subarachnoid haemorrhage (aSAH) is a sudden onset of severe headache, which can be accompanied by meningism, impaired consciousness, and vegetative symptoms. A cerebral CT scan is the initial diagnostic tool of choice if aSAH is suspected. The localisation and morphology of the aneurysm is depicted in a CT-angiography and/or conventional panangiography. Until definitive exclusion of the aneurysm by either microsurgical clipping or endovascular coiling, rebleeding should be avoided implicitly. The postoperative phase, especially in patients with severe aSAH is embossed with the occurrence of disease-specific complications (cerebral vasospasm, intracranial hypertension, seizure disorder, hydrocephalus) and consecutively increased risk for secondary brain injury. Furthermore, many patients present systemic complications such as electrolyte disturbances and cardiac dysfunctions. Early identification and therapy of cerebral and systemic complications are very important in order improve functional outcome.

The disease pattern <> describes a local frontal-bone osteomyelitis that arises from an external infection with consecutive sub-periostal expansion. Symptoms may develop slowly or not at all with a mostly indolent protuberance on the patient's forehead. Symptomatic illness often indicates secondary morbidities. Here, we present a complicated case with intracranial dissemination.

Glioblastoma multiforme (GBM) is the most frequently encountered malignant cerebral tumor. Despite significant improvements in the treatment of GBM, this disease remains associated with a high morbidity and mortality, with more than half of all affected patients dying within the first year after diagnosis. Typical symptoms include focal neurological symptoms, seizures, personality changes and neurocognitive symptoms. GBM can be identified by means of cerebral imaging modalities and subsequently confirmed histopathologically through biopsy or resection. At present, surgical resection followed by radiotherapy with concomitant chemotherapy with temozolomide and subsequent adjuvant chemotherapy with temozolomide is considered the standard therapy for patients with GBM. Currently, many interdisciplinary studies with glioblastoma patients are accomplished with the aim to further improve the prognosis of the affected patients.

The carpal tunnel syndrome is the most common entrapment neuropathy (about 3% of the adults are affected). It is characterized by pain and paresthesia along the distribution of the median nerve. Thenar muscle atrophy with corresponding muscle weakness is a late manifestation of advanced disease. Electrophysiological tests are helpful in suggesting the diagnosis. An imaging with a magnetic resonance tomography may be used in the diagnosis of atypical cases. Ergonomic manoeuvres, oral steroids and steroidal injections may alleviate symptoms in mild cases. Surgical decompression of the carpal tunnel is the classical treatment of severe cases as well as for those who do not respond to conservative treatment. After surgery patients usually show excellent results. The following article discusses clinical aspects, diagnosis and current therapeutic options.

The trigeminal neuralgia is characterised by paroxysmal appearing fulgurous stabbing pain. Its medical condition is caused through a local-circumscribed demyelinisation of the trigeminal nerve with consecutive conduction of salting impulses on afferent pain fibres. It is essential to differentiate the symptomatic from the idiopathic trigeminal neuralgia. As primary management, a pharmacological treatment with anticonvulsants is recommended in order to attenuate the ectopic-generated pain impulses. Different neurosurgical procedures are available in cases of resistance to therapy. Thereby, causal surgery in form of microvascular decompression is not only the operative treatment of choice, but because of the excellent results also a fundamental support of the theory of vascular compression. A comprehensive knowledge about diagnosis and management of trigeminal neuralgia is essential to treat patients efficiently and successfully. This synopsis summarises the current recommendations concerning diagnostics and therapeutic options.

Dissection of extra- and intradural arteries is a common cause of cerebral insult in younger patients (<45 years). In patients with corresponding craniocervical injury and symptoms (carotidynie, ipsilateral headache, partial Horner syndrome, cranial nerve palsy) arterial dissection is always to be considered. Essential in diagnosing arterial dissection is the verification of the intramural hematoma and morphologic changes in the vessel (stenosis, pseudoaneurysm) by means of CT/CTA (acute phase) or MRI/MRA (subacute phase). These patients need to be monitored in an intensive care unit setting. The acute therapy includes anticoagulation or inhibition of thrombocyte aggregation. We present two cases with delayed cerebral infarction due to traumatic extra- and intradural arterial dissection after a motor vehicle accident. To perform primary diagnostic quickly and adequately may avoid permanent neurological deficit in these patients.

Normal pressure hydrocephalus (NPH) is characterized by the classic triad of symptoms including gait disturbance, urinary incontinence, and dementia. Gait impairment represents the cardinal symptom. NPH is associated with a radiological verifiable ventriculomegaly in the absence of elevated cerebrospinal fluid (CSF) pressure. Because many patients do not present with classical clinical and radiological findings, its diagnosis and management represents a challenge for the general practitioner, neurologist and neurosurgeon. Various supplemental preoperative tests, including lumbar CSF tap test or CSF outflow resistance determination, can improve the accuracy of predicting a response to surgical intervention. CSF shunt results in significant symptoms in the majority of appropriately evaluated patients. The following article discusses clinical aspects, diagnosis and current therapeutic options.

A considerable part of the medical clinical daily routine incorporates the information of patients about medical diagnosis and especially about the scheduled operative intervention. The disease pattern, the course in the hospital before and after surgery and the operation itself will be discussed during these conversations. The patient has to be informed about all potential complications from a medico legal point of view. To optimise information delivery, auxiliary materials like charts, pictures, X-rays and models are used. Unfortunately, only a small percentage of the presented information is assimilated by the patient after strict verbal information. To inform patients better and earlier about medical details and internal processes before the operation, we developed a web-based audiovisual patient information system with a combination of pictures, text, tone and video about surgical interventions. The patient satisfaction could be markedly improved by the application of this patient information system in the informed consent process. Furthermore, the use of the web-based multimedia information portal may leads to an essential time saving for the medical staff.

Malignant gliomas, among others the glioblastoma multiforme, are the most frequent brain tumors. The glioblastoma itself represents the most unfavorable tumor. In Switzerland, about 450 humans contract a glioblastoma each year. The median survival time is under 12 months, thus the prognosis is dismal despite a combination of surgery, radiotherapy and chemotherapy. Surgical resection presents the major constituent in the management of patients with a glioblastoma. Postoperative radio- and chemotherapy have beneficial effects on the survival time and quality of life. Surgical removal of glioblastomas is challenging due to their infiltrative growth pattern. Therefore, the target extent of resection can only be achieved partially. For some time now, a new in Germany developed method is used in the Neurosurgical Clinic of the Cantonal Hospital in St. Gallen: The 5-ALA-guided microsurgical resection method allows a targeted and secure surgical resection of the tumor. A preoperative administered substance colors the tumor and makes it better visible for the neurosurgeon. Consequently, the healthy brain tissue can be better distinguished from the tumor. This permits not only a larger complete surgical resection of the tumor but also minimizes the resection of healthy tissue.

Up to 10% of patients with low back pain develop chronic low back pain. By definition, this is a pain that has persisted for longer than three months. Patients with chronic low back pain suffer from a disease, which has serious effects on the psycho-social and physiological integrity of the persons concerned. Pain syndromes of the lumbar region are among the greatest health care system problems in industrialised countries with direct and indirect annual costs of 150 to 250 billion Swiss francs. Despite intensive treatment some patients remain symptomatic. Out of it results a complaint-driven functional under-utilisation, which leads to an alleviation of the performance and increased inactivity - the beginning of a vicious circle. A multimodal treatment concept including physio- and psychotherapy, supported by a targeted medicamentous therapy, normally improves physical functions and achieves a significant discomfort reduction. If resistance to therapy persists, it is suggestive to consider precociously minimal-invasive or invasive therapeutic options.

The lumbar spinal stenosis (LSS) is defined as a narrowing of the spinal canal together with neuronal and vascular structures via circumjacent bone and soft tissue. In patients aged over 65 years, the LSS is among the most frequent causes of lumbago, either with or without sciatica. The prevalence will continue to augment because of the increased life expectancy. The leading symptom is neurogenic claudicatio with lumbogluteal or sciatic pain, which occurs while walking and leads to a limitation of the walking distance. Its typical constellation of symptoms including subjective leg weakness is leading to the tentative diagnosis. Nowadays, the imaging technique of choice for the diagnosis is magnetic resonance imaging. A conservative treatment is initially sufficient in most cases. The indication for surgery is given, if the pain and limitation of walking distance are not tolerable any more. Additional fusion should be taken into account, when degenerative spondylolisthesis or other pathomorphological alterations result in an instability. Conservative and surgical therapeutic goals imply pain relief, amelioration of the physical functionality, mobility and general quality of life.

Acute low back pain is one of the most frequent reason for an emergency or primary care physician visit. Up to 90% of all adults will experience an episode of back pain at some point during their lifetime. Although the majority of patients have uncomplicated benign presentation and 80-90% recover within 4 to 6 weeks, there is a small subset who has an underlying potential life-threatening etiology. Among them are aortic dissection, ruptured abdominal aortic aneurysm, vertebral osteomyelitis, spinal epidural abscess and the cauda equina syndrome (CES). The latter entails a compression of the nerve roots of the cauda equina. These patients usually present post-traumatically with the clinical triad of saddle anesthesia, bowel or bladder dysfunction and muscular weakness of the lower extremeties. A delayed diagnosis can result in a significantly increased morbidity. Therefore, early diagnosis and the initiation of the appropriate therapeutic steps are essential. A thourough anamnesis and physical examination are leading to the suspected diagosis. Below, clinical presentation, diagnosis and relevant treatment of the CES are discussed.

Acute low back pain is a very common symptom. Up to 90% of all adults suffer at least once in their life from a low back pain episode, in the majority of cases a nonspecific lumbago. They are, with or without sciatica, usually self-limited and have no serious underlying pathology and subside in 80-90% of the concerned patients within six weeks. Beside a sufficient pain medication and physiotherapy, reassurance about the overall benign character and the favourable prognosis of the medical condition should be in the centre of the therapeutic efforts. A more thorough assessment is required for selected patients with warning signs, so called "red flags" findings, because they are associated with an increased risk of cauda equina syndrome, cancer, infection, or fracture. These patients also require a closer follow-up and, in some cases, an urgent surgical intervention. Among patients with acute nonspecific mechanical low back pain, imaging diagnostic can be delayed for at least four to six weeks, which usually allows the medical condition to improve. From a therapeutic viewpoint, there is enough evidence for the effectiveness of paracetamol, nonsteroidal anti-inflammatory drugs, skeletal muscle relaxants, heat therapy, physiotherapy, and the advice to stay "active". A complete relief and protection represent an out-dated concept, because the deconditioning is stimulated and the return to the workplace is needlessly delayed. Spinal manipulative therapy may provide short-term benefits in certain patients. In a multimodal therapeutic concept, the patient education should focus on the natural history of an acute back pain episode, the overall good prognosis, and recommendations for an effective treatment.

Whiplash injuries of the cervical spine are of paramount clinical and socioeconomic importance. To date, many problems in regard to diagnosis, classification, treatment and assessment have not been sufficiently solved. Diagnosis is often made subjectively and the ideal mode of treatment is still the subject of controversy. Scientific progress has lead to the development of a prognostic classification system, objective diagnostic tests, different treatment modalities and, perhaps most importantly, the production of more secure automobiles. Current scientific evidence of the assessment and treatment of whiplash injuries is only partially integrated into clinical routine, although modern strategies of combining medicamentous therapy with early physiotherapy has shown good results. Clear dignostic criteria and treatment guidelines would conquer the cost explosion associated with whiplash injuries largely evident in the Swiss-German population.

Mild traumatic brain injury (TBI) is a reversible brain damage, without structural changes, which is caused by an external force. By definition, patients with mild TBI have a GCS of 13-15. It is an established risk factor for both morbidity and mortality. Prognosis is dependent on the primary damage incurred as well as secondary damage, for example, posttraumatic bleeding and oedema. Initial management should focus on the identification of patients at risk for serious intracranial pathologies. Investigations should be directed towards the severity of the injuries. Notably, the conventional X-ray is inadequate for the assessment of TBI. The following article discusses practical algorithms for the management of mild TBI and the indications for early use of CT.