Search

Background:  Percutaneous pedicle screw fixation in obese patients remains a surgical challenge. We aimed to compare patient-reported outcomes and complication rates between obese and nonobese patients who were treated by minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF)., Methods:  The authors retrospectively reviewed patients who underwent MIS-TLIF at a single institution between 2011 and 2014. Patients were classified as obese (body mass index [BMI] ≥30 kg/m 2 ) or nonobese (BMI < 30 kg/m 2 ), according to their BMI. Outcomes assessed were complications, numerical rating scale (NRS) scores for back and leg pain, Oswestry Disability Index (ODI), and 36-Item Short-Form Survey (SF-36) scores., Results:  The final study group consisted of 71 patients, 24 obese (33.8%, 34.8 ± 3.8 kg/m 2 ) and 47 nonobese (66.2%, 25.4 ± 2.9 kg/m 2 ). Instrumentation failures (13.6 vs. 17.0%), dural tears (17.2 vs. 4.0%), and revision rates (16.7 vs. 19.1%) were similar between both groups ( p  > 0.05). Perioperative improvements in back pain (4.3 vs. 5.4, p  = 0.07), leg pain (3.8 vs. 4.2, p  = 0.6), and ODI (13.3 vs. 22.5, p  = 0.5) were comparable among the groups and persisted at long-term follow-up. Obese patients had worse postoperative physical component SF-36 scores than nonobese patients (36.4 vs. 42.7, p  = 0.03), while the mental component scores were not statistically different ( p  = 0.09)., Conclusion:  Obese patients can achieve similar improvement of the pain intensity and functional status even at long-term follow-up. In patients with appropriate surgical indications, obesity should not be considered a contraindication for MIS-TLIF surgery., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective  Computer-aided design and manufacturing (CAD/CAM) implants are fabricated based on volumetric analysis of computed tomography (CT) scans and are routinely used for the reconstruction of orbital fractures. We present three cases of patients with sphenoorbital meningiomas that underwent tumor resection, orbital decompression, and orbital reconstruction with patient specific porous titanium or acrylic implants in a single procedure. Methods  The extent of bone resection of the sphenoorbital meningiomas was planned in a virtual three-dimensional (3D) environment using preoperative thin-layer CT data. The anatomy of the orbital wall in the resection area was reconstructed by superimposing the contralateral unaffected orbit and by using the information of the neighboring bony structures. The customized implants and a corresponding craniotomy template were designed in the desired size and shape by the manufacturer. Results  All patients presented with a sphenoorbital meningioma and exophthalmos. After osteoclastic craniotomy with the drilling template, orbital decompression was performed. Implant fitting was tight in two cases and could be easily fixated with miniplates and screws. In the third patient, a reoperation was necessary for additional bone resection, as well as drilling and repositioning of the implant. The postoperative CT scans showed an accurate reconstruction of the orbital wall. After surgery, exophthalmos was substantially reduced and a satisfying cosmetic result could be finally achieved in all patients. Conclusions  The concept of preoperative 3D virtual treatment planning and single-step orbital reconstruction with CAD/CAM implants after tumor resection involving the orbit is well feasible and can lead to good cosmetic results., Competing Interests: Conflict of Interest None., (© Thieme Medical Publishers.)

The coexistence of aneurysms and meningiomas is rare, and encasement of an aneurysm within a meningioma even more so. We report a case of an optic nerve sheath meningioma encasing an aneurysm of the internal carotid artery and present a brief review of the literature., (Georg Thieme Verlag KG Stuttgart · New York.)

Tension pneumocephalus is a rare complication that can occur after craniofacial resection of lesions of the anterior skull base. Early diagnosis is important to avoid potential serious neurologic deficits, including death. It has been associated with the perioperative placement of a lumbar drainage and with esthesioneuroblastoma. Therapy consists of evacuation of the intracranial air as well as conservative measures. Here we report a case of a patient with an ethmoidal esthesioneuroblastoma who underwent a traditional microsurgical craniofacial resection and developed a delayed epidural tension pneumocephalus. This was treated by performing an incision in the pericranial flap covering the anterior cranial base defect using an endonasal endoscopic approach. To our knowledge, this particular treatment technique has not been reported before in this context., (Georg Thieme Verlag KG Stuttgart · New York.)

Adhesion and aggregation are important parameters characterizing the function of intact platelets in flowing blood and in contact with a more or less thrombogenic surface. In the retention test Homburg (RTH), platelets are exposed to a standardized textured surface (Sysmex retention tubes) under defined conditions of flow. Platelet counts are performed before and after the Sysmex retention tube passage. The difference between these values indicates the percentage of retained platelets (retention index). Decreased retention in the RTH indicates a loss of function or defective platelet function; increase is associated with an increased activation of platelets, for example, in patients with vascular diseases. For further evaluation of the retention phenomenon the filters were fixed after cell passage and examined by scanning electron microscopy (SEM) and transmission electron microscopy (TEM). SEM and TEM micrographs show activated platelets adhering and spreading on the filter surface, comparable with platelets on a disturbed endothelium. Also, we examined the influence of different G forces and centrifugation times on the retention behavior of the platelets in citrated platelet-rich plasma (PRP) and whole blood (WB). G forces influenced the retention index in PRP and WB significantly and in a different way. Finally, we used a platelet standard, as customary in the quality check, to determine the serial as well as the day-to-day precision.

Decreased retention in the retention test Homburg (RTH) indicates a loss of platelet function; increase is associated with an increased activation of platelets, for example, in patients with vascular diseases. Compared with other materials (e.g., collagen, glass pearls, etc.) the filter surface in the retention tubes is nonthrombogenic. Therefore, the RTH seems to be well suited for measuring an in vivo over-reactivity of platelets. In a pilot study using the RTH we evaluated the postoperative over-reactivity of platelets in 14 patients and observed a significant heterogeneity of the platelet population concerning size and stickiness. Reliable platelet function tests are also necessary for "drug monitoring," since they deliver important clinical laboratory parameters for efficient control of a therapy with antiplatelet drugs. Therefore, we evaluated in vitro how, after administration of platelet aggregation-inhibiting medications (such as acetylsalicylic acid, Prostaglandin and ReoPro in various concentrations, the adenosine diphosphate (ADP), collagen, ristocetin, or suprarenin increased retention can be reduced. The reaction of the platelets in platelet-rich plasma of different patients or donors to the addition of ADP is variable. The platelet function inhibitor effect is dose dependent. In a clinical pilot study, a significant platelet-inhibiting effect of clopidogrel using the RTH has been shown.

Objective: This investigation was performed to evaluate the specific procedural issues and indications of a surgically assisted Doppler-guided endovascular transfalcine venous approach for the treatment of vein of Galen aneurysmal malformations (VGAM) in critically ill neonates., Patients and Methods: Two neonates out of a clinical series of 15 children (8 males and 7 females) with vein of Galen malformations were treated by our neurovascular team, using a combined surgically assisted endovascular transfalcine approach. In the biplanar angiography room a radiographically guided craniotomy (1.5 cm) was placed over the cranial projection of the falciforme sinus. After craniotomy the orthograd flow of the falciforme sinus was identified by Doppler ultrasonography. The sinus was punctured by an i. v. cannula with injection port and was sutured to the skin. A microcatheter was maneuvered over a guide into the malformation under fluoroscopic control. For embolization Guglielmi electrolytically detachable platinum coils were placed into the malformation as an embolic agent. Neurological examination records, available MR images, computed tomographic scans, pre- and postembolization angiograms and follow-up data were analyzed., Results: In both individuals the malformation was classified as VGAM. The follow-up was 6 and 7 months, respectively. No technique associated morbidity or mortality occurred in the present series. At discharge both selected neonates were in stable condition and the flow in the VGAMs could be significantly reduced by a combination of approaches including the venous transfalcine approach. Meanwhile, 6 months after birth one neonate died due to a deterioration of the pulmonary hypertension., Conclusions: Endovascular treatment is presently the most efficient strategy to allow neonates and infants survive the early manifestation of vein of Galen malformations and probably render a normal neurological development. Consequently, a combination of approaches in selected cases including the Doppler guided venous transfalcine route should be regarded as a preferential treatment modality, especially in patients with arterial vasospasms and venous stenosis.

In correlation with increased life expectancy of patients, quality of life (QOL) has become a factor of increasing interest by the patient himself and also of importance in health-care planning and recruitment of financial resources. In this context, self-monitoring of long-term anticoagulant treatment might be a strategy that could mean a step forward in health-related as well as general life satisfaction for patients participating in self-monitoring programs. Also, the new strategy of increased home-control of anticoagulant treatment illustrates the complexity of multiple factors that can lead to changes in the subjective feeling and objective aspects of QOL. Our intention in a pilot study was to probe the feasibility of QOL research and relevant factors of influence by retrospectively evaluating data from two groups of outpatients seen in a large treatment center. The high frequency (n = 8 in sample 2) of disturbed sleep as a simple screening indicator stresses the probable importance of undetected depression, which might require treatment and could confound research as to QOL. Instruments to measure QOL in oral anticoagulation self-monitoring should therefore be adapted to the heterogeneous structure of factors in the target population, and include psychological parameters, especially in regard to health-related locus of control and mood.

Self-control and self-management of oral anticoagulant therapy have become more and more attractive for patients undergoing long-term treatment. In our training center, we examined 50 patients who took part in a standardized training course for self-management. Patients (36 men, 14 women) were preselected according to the guidelines of the German Association for Self-management of Oral Anticoagulation (ASA e.V.) and were all trained by the same physician. The complete course took an average of eight sessions. Patients older than 59 years needed significantly more training time in theoretical advising than younger patients; they did not need more training time in practical matters. The values between International Normalized Ratio (INR) measured in venous blood samples and by self-assessment were comparable for both groups. There was a good overall correlation between self-controlled INRs and laboratory assays, however, the self-assayed INRs were significantly lower than those from the venous blood samples.

In contrast to other European countries, in Germany more than 90% of oral anticoagulated patients are controlled by general practitioners. The International Normalized Ratio (INR) system in laboratory control is not in widespread use, often leading to misinterpretations of prothrombin time (PT) measurements. To improve the management of anticoagulated patients, a model was developed, consisting of different questionnaires and on the base of the INR system. Since 1993, 60 patients in our Department's outpatient anticoagulant clinic and since 1996 16 patients in the office of a general practitioner were followed for 146.32 patient years. There were no thromboembolic events and no major bleedings during follow-up. A total of 126 minor bleedings occurred in 30 patients. There were no significant differences in INR values and stable phases between the two centers; however, significantly shorter stable phases in patients with bleeding episodes were noted. Thus, this model seems to be useful also in general practitioners' hands.

A 9-year series of 45 intracranial and spinal hematomas in patients under oral anticoagulant treatment with phenprocoumon was analyzed and compared to data from the literature. In 42% of the patients, International Normalized Ratio (INR) values >4.5 were found on admission, 36% were older than 70 years and most patients (38%) were under long-term treatment after cardiac valve replacement. Patients who recovered did not report to have given informed consent at the start of anticoagulant therapy. Because an average of five serious hemorrhages are reported/year from German neurosurgical departments, it can be estimated that about 650 intracerebral or intraspinal hematomas, including about 250 fatalities/year occur in Germany under oral anticoagulant treatment. These complications reach the same incidence than spontaneous hematomas either from aneurysms or angiomas. Standards for indications, clinical control, quality INR testing and INR targets not exceeding 4.0, and collecting more data on incidences and causative factors of complications may be an important contribution to reduce these fatalities.

Overdose or bleeding with oral anticoagulation requires gradual antagonization of the drugs. Minor bleedings are most commonly managed by temporarily discontinuing treatment and by giving vitamin K to antagonize the coumarin derivative effects. Major bleedings, in contrast, especially intracranial hemorrhages, require immediate antagonization of anticoagulation. This is also necessary in required major surgery of anticoagulated patients. Instant normalization of hemostasis in such cases is achieved by the administration of clotting factors, in particular prothrombin complex concentrates. The use of fresh frozen plasma, instead, is less useful. The treatment with prothrombin complex concentrates requires a strict risk-benefit estimation and laboratory monitoring is recommended to optimize dosage adjustment. A 2-year follow-up of 45 out-patients receiving phenprocoumon at our center revealed a total of 11 bleeding complications (11.6/100 treatment-years, 10 minor and 1 major bleeding). Discontinuing or reducing oral anticoagulation together with vitamin K were the methods most frequently used to efficiently manage hemorrhages, whereas prothrombin complex concentrates were only used in one case with major bleeding. Oral anticoagulation appeared to be an enhancing factor for an otherwise existing bleeding diathesis rather than a genuine cause for hemorrhages.