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INTRODUCTION Despite some evidence that anxiety may affect length of stay (LOS), relatively little inquiry exists regarding this in neurosurgical literature. OBJECTIVE To determine the influence of anxiety on LOS after elective lumbar decompression and fusion (LDF) surgery. METHODS The medical records of 307 patients who consecutively underwent elective LDF surgery from October 1, 2010, through September 30, 2013, were retrospectively reviewed. Each patient's medications and comorbidities were determined using the medical history. The impact of their medications on LOS was studied using multivariate analysis. Linear regression was also used to assess the relationship between anxiolytic use and LOS. An independent sample t test was used to compare the mean LOS of the group of patients receiving muscle relaxants with that of the group who were not. RESULTS Those with a diagnosis of anxiety who were taking anxiolytics (n = 32) stayed 1.8 days longer than those with no diagnosis of anxiety and who were not taking anxiolytics (n = 224) after LDF surgery (p = 0.003). Those with a diagnosis of anxiety who were taking anxiolytics (n = 32) stayed 1.9 days longer than those with no diagnosis of anxiety and who were taking anxiolytics (n = 24) after LDF surgery (p = 0.003). CONCLUSION Our study suggests that those with a diagnosis of anxiety who take medications for that condition have a longer LOS than those with no diagnosis of anxiety and who are not medicated for the condition. This could be because these patients are more vulnerable to states of anxiety when required to be nil per os for 12 hours before surgery.

Chronic back pain is commonly associated with physical and mental comorbidities, which create a considerable burden on the healthcare system. We examined the differences in comorbidity rates of 619 spinal surgery patients of employment age, and the impact of comorbidity rates on length of hospital stay and cost. The charts of patients aged >25 years and

Complex shifts in demography combined with drastic advancements in spinal surgery have led to a steep increase in often expensive spinal interventions in older and obese patients. A cost analysis, based on hospital charges, was performed retrospectively on the spinal surgery of 787 randomly selected patients who were operated at The Medical Center of Central Georgia, a large urban hospital in Central Georgia. The types of surgery included anterior cervical decompression and fusion (ACDF), lumbar decompression and fusion (LDF), and lumbar microdiscectomy (LMD). The distribution of patient age followed a Gaussian form. The peak age for patients was 50–59 years (28.8%), and there was no statistical difference in age between men and women. The body mass index (BMI) differed ( p 2 ; range: 18–47 kg/m 2 ) and females (30.69 kg/m 2 ; range: 17–58 kg/m 2 ). The BMI data did not follow a Gaussian distribution for either gender. The hospital cost for spinal surgery increased with age except for male patients who underwent ACDF. For male patients who underwent LDF, the increase in hospital cost was statistically significant between the 40–49-year and the ⩾70-year age groups. Univariate analysis with type of surgery as a covariate showed that age was a significant determinant of hospital cost ( p = 0.000), and BMI was not ( p = 0.110); however, the interaction between age and BMI was significant ( p = 0.000). Older patients undergoing spinal surgery had lower BMI, more so in males ( r = −0.047, p = 0.426) than in females ( r = −0.038, p = 0.485). There were linear trends in all gender–spinal surgery categories between age, BMI and hospital cost. Older female patients who underwent LDF tended to have a lower BMI but higher hospital cost, confirming that age was more important than BMI in determining hospital cost in these patients. The increments in cost of spinal surgery in relation to age especially and BMI were, nevertheless, small. We believe that spinal surgery in the elderly should be viewed as a public investment, as the modern concept of retirement involves people working intermittently up to their 80s. Thus, where clinical research on medical costs is to be conducted, cost analysis needs to be expanded to include returns to government in the form of taxes.

Clinical information suggests that opioid dependence is a major contributor to poor outcomes involving health status and to increased length of stay in hospital settings. Before spine surgery, 150 patients who were using an opioid medication for pain relief were interviewed using the six World Health Organization (WHO) guidelines for the diagnosis of opioid dependence. Three groups were defined: opioid-dependent, nonopioid-dependent, and a subclinical group. Results revealed an average of 20% of patients ( N = 30) who met the WHO criteria for the diagnosis of opioid dependence. There were significant positive correlations between age and number of positive WHO criteria, length of stay, and time under surgery. Length of stay was significantly higher for the older age group (> 55 yr.). ANCOVA analysis using two opioid dependence groups (+ and -) and age group as independent variables affecting length of stay, after controlling for type of surgery, pain intensity, and number of previous spine surgeries, revealed that effects of opioid dependence status and age were significant but their interaction was not. Age did add length of stay independently of opioid dependence status; older adults remain in the hospital longer for various reasons probably associated with comorbidities.

Background context Somatosensory evoked potential (SSEP) is used to monitor integrity of the brain, spinal cord, and nerve roots during spinal surgery. It records the electrical potentials from the scalp after electrical stimulation of the peripheral nerves of the upper or lower limbs. The standard monitoring modality in lumbosacral spine surgery includes lower-limb SSEP and electromyography (EMG). Upper-limb SSEP monitoring has also been used to detect and prevent brachial plexopathy and peripheral nerve injury in thoracic and lumbosacral spine surgeries. We routinely monitor lower-limb SSEP and EMG in lumbosacral spine procedures at our institution. However, a few patients experienced postoperative numbness and/or pain in their ulnar distribution with uneventful lower-limb SSEP and EMG. Purpose We hypothesized that the postoperative upper extremity paresis in lumbosacral surgeries may result from compression and/or stretch of the brachial plexus and/or ulnar nerve while the patients were in prone position. Using upper-limb SSEP, we investigated whether we observe any significant change in the SSEP, and if so, whether we can prevent or reduce frequency of postoperative upper extremity deficits. Study design/setting In this prospective study, we monitored upper-limb SSEP, in addition to lower-limb SSEP and EMG, in 230 elective, posterior lumbosacral spinal procedures. All operations were performed by a group of four neurosurgeons. Patient sample One hundred and thirty-one female and 99 male with an age range of 28 to 86 years between January 2004 and December 2005 were studied. Outcome measures Amplitude and latency of upper-limb or ulnar SSEP were continuously compared with those of the baseline. A greater than or equal to 50% decrease in SSEPs amplitude and/or a greater than or equal to 10% increase in latency were considered to be significant. Methods After intubation, patients were positioned prone on Jackson or Andrews spinal table. Anesthesia was maintained with inhalant gas (desflurane or sevoflurane) and propofol infusion with and without minimal infusion of narcotics (fentanyl, sufentanyl, or remifentanil). Intraoperative neurophysiologic monitoring of upper-limb or ulnar SSEP was achieved by continuously recording cortical and subcortical responses after alternate stimulation of the ulnar nerve at the wrist. In our institutional protocol, a greater than or equal to 50% decrease in SSEPs amplitude and/or a greater than or equal to 10% increase in latency were considered to be significant to alert the operating surgeons. When significant changes occurred, the surgeon was immediately notified. Also, reevaluation of vital signs, depth of anesthesia, and patient's position, and technical troubleshootings were subsequently followed. Results We observed a greater than or equal to 50% decrease in amplitude of ulnar SSEP in 10 patients without significant changes in lower-limb SSEP (peroneal or posterior tibial nerve SSEP) or EMG during surgery. Eight patients had changes in unilateral limbs, and two patients had changes in bilateral limbs. Two patients with significant changes in unilateral limbs showed changes twice. The mean SSEP amplitude for the 14 changes was 29.2±3.1% (mean±SEM, standard error of mean) of the baseline value at the average surgical time of 60±1.5 minutes. With repositioning of the arms, the amplitudes were immediately restored with the average of 70.2±7.1% (n=14) of the baseline value. The mean amplitude of upper-limb SSEP was 73.4±8.7% (n=12) of the baseline at wound closure. The average surgical time was 154±29.2 minutes per case for the 10 patients. There was no documented postoperative upper extremity paresis in all 230 patients. Conclusions The present study demonstrates that upper-limb SSEP monitoring could detect position-related ulnar neuropathy in 5.2% of the patients undergoing lumbosacral spine surgery.

Study design Prospective, clinical study. Objective The objective of our study was to evaluate the role of laryngeal intraoperative electromyography (IEMG) in predicting the development of postoperative recurrent laryngeal nerve (RLN) palsy in patients undergoing anterior cervical discectomy and fusion (ACDF). We also attempted to develop a method to quantify the total IEMG irritation of the RLN. Summary of background data RLN injury has been recognized as the most common ACDF-associated neurologic injury. It has been postulated, that the employment of laryngeal IEMG may identify the operative events leading to RLN injury and subsequent postoperative palsy. Methods Laryngeal IEMG monitoring was performed in 298 patients undergoing ACDF. Preexistent baseline EMG activity, amplitude, and duration of IEMG activity were recorded. The total amount of RLN irritation was expressed as an Irritation Score (IS) applying a specially designed mathematical equation incorporating the amplitude, the duration, and the presence of any baseline EMG irritation. The relationship of IEMG activity with parameters such as the number of operative levels, the duration of the procedure, the presence of any previous neck surgeries, and the type of the used retractor was examined. Results IEMG activity was recorded in 14.4% of our patients. Postoperative RLN injury occurred in 2.3% of our patients. The sensitivity of IEMG was 100%, the specificity 87%, the positive predictive value 16%, and its negative predictive value 97%. The calculated IS ranged between 0.28 and 3.47 (mean IS: 2.09). Significantly increased IEMG activity was found in patients with previous surgical intervention, patients undergoing multilevel procedures, long-lasting procedures, and cases in which self-retained retractors were used. Likewise, significantly increased IS were observed in patients with previous surgeries and in cases where self-retained retractors were used. Conclusions Our study indicates that laryngeal IEMG is a high-sensitivity modality that can provide real-time information and can potentially minimize the risk of operative RLN injury.

Object The association of vitreous and/or subhyaloid hemorrhage with aneurysmal subarachnoid hemorrhage (SAH) has been frequently identified since the original description by Terson in 1900. In this prospective clinical study the authors examined the actual incidence of Terson hemorrhage in patients suffering aneurysmal SAH, they attempted to identify those parameters that could predispose its development, and they evaluated its prognostic significance in the overall patients' outcome. Methods A total of 174 patients suffering aneurysmal SAH were included in this study. The admitting Glasgow Coma Scale scores (GCS), World Federation of Neurological Societies (WFNS) scale scores, Hunt and Hess grades, and Fisher grades were recorded. A careful ophthalmological evaluation was performed in all participants. The exact anatomical locations and the largest diameter of the dome of the ruptured aneurysms were also recorded. Surgical clipping or endovascular coiling was used in 165 patients. Clinical outcome was evaluated at discharge from the hospital by using the Glasgow Outcome Scale and the modified Rankin Scale. Periodic ophthalmological evaluations were performed for 2 years. Results In this series, the observed incidence of Terson hemorrhage was 12.1%. Statistical analysis of our data demonstrated that patients with low GCS scores and high WFNS scores, Hunt and Hess grades, and Fisher grades had an increased incidence of Terson hemorrhage. The mortality rate for patients with Terson hemorrhage was 28.6%, whereas that for patients without Terson hemorrhage was 2.0%. Moreover, patients with Terson hemorrhage who survived had significantly worse outcomes than those in patients without Terson hemorrhage. Conclusions Terson hemorrhage constitutes a common SAH-associated complication. Its incidence is increased in patients with low GCS and high WFNS scores, and high Hunt and Hess and Fisher grades. Its presence is associated with increased mortality and morbidity rates.

We present the results of a retrospective study employing intraoperative micro-Doppler ultrasonography (MDU) in verifying proper clip placement during cerebral aneurysmal surgery. One hundred and thirty-four patients surgically treated for 147 intracranial aneurysms were studied. Thirteen patients harboring 17 aneurysms were surgically treated on an elective basis, while 121 patients with 130 aneurysms, presented with subarachnoid hemorrhage (SAH). Blood flow velocities of the parent and adjacent vessels as well as the aneurysmal sac were measured using a Conforma Micro-Doppler (Cook Vascular Inc., Leechburg, PA, USA). Pre- and post-operative cerebral angiography was obtained in all our patients. In 23 aneurysms (15.6%) there was decreased or absent flow in the parent vessel or in one of the adjacent vessels after clipping. In another 19 aneurysms (12.9%), MDU demonstrated flow through the aneurysmal dome even though the aneurysmal neck appeared to be totally obliterated. Presence of SAH, anatomic location and size of the aneurysm were associated with improper clip placement in a statistically significant fashion. The false positive rate for MDU was 2% while there were no false negative findings in our study. MDU appears to be a non-invasive, reliable alternative methodology to intra-operative angiography. This inexpensive method may lend itself to routine usage in aneurysm surgery.

Objective: This study describes a single-site investigation on the effects of a randomized double-blind placebo trial targeting duloxetine added to opioid use (duloxetine + opioid) against a comparator (placebo + opioid) in spine surgery patients, independent of major depression. Design: The double-blind comparator study assessed two groups on opioids: one using duloxetine and the other a placebo. Subjects were administered the respective medication 2 weeks prior to surgery and continued on this for more than 3 months. Subjects were assessed at three times: prior to surgery, 4 weeks postsurgery, and 12 weeks postsurgery. They completed a battery of tests assessing for pain, adjustment, and psychiatric problems. Setting: Neurosurgical outpatient and inpatient setting. Patients: Sixty-eight patients completed the study. They received one of three types of elective spine surgery. Interventions: Subjects were given duloxetine or placebo 2 weeks prior to surgery and continued with the regimen for more than 3 months. Outcomes: The primary focus was pain and second on adjustment factors and psychiatric symptoms: depression and anxiety. The amount of opioid use presurgery and postsurgery was also evaluated. Results: There were differences among the groups on Brief Pain Inventory (BPI)-Average, the core pain marker, and BPI-Sleep. Within-subject analyses showed that duloxetine subjects improved significantly from baseline. For function, post-CIBIC and post-Functional Adjustment Questionnaire were significant, favoring duloxetine. Reduction of opioid use was not a factor; both groups' utilization declined. For affect, both groups were significantly improved over time. Conclusions: Duloxetine seems to improve pain, assist with maintaining function, and reduce intensity of affect.

Traumatic epidural hematoma (EDH) represents a rare head injury complication in infants. Its diagnosis can be quite challenging because its clinical presentation is usually subtle and nonspecific. In our current communication, we present our data regarding the presentation of infants with EDH, their management, and their long-term outcome. In a retrospective study, the hospital and outpatient clinic charts and imaging studies (head CT and skull X-rays) of 31 infants with pure, supratentorial EDH of traumatic origin were meticulously reviewed. Children Coma Scale score and Trauma Infant Neurologic Score (TINS) were also reviewed. The most common presenting symptom was irritability, which occurred in 18/31 (58.1%) of our patients. Pallor (in 30/31 patients) and cephalhematoma (in 21/31 patients) were the most commonly occurring clinical signs upon admission; both signs represent signs of significant clinical importance. Surgical evacuation via a craniotomy was required in 24/31 of our patients, while 7/31 patients were managed conservatively. The mortality rate in our series was 6.5% (2/31 patients), and our long-term morbidity rate was 3.2% (1/31 patients). EDH in infants represents a life-threatening complication of head injury, which requires early identification and prompt surgical or conservative management depending on the patient’s clinical condition, size of EDH, and presence of midline structure shift on head CT scan. Mortality and long-term morbidity are low with early diagnosis and prompt treatment.

The fusion rate represents one of the most commonly used criteria for evaluating the efficacy of spinal surgical techniques and the effectiveness of newly developed instrumentation and spinal implants. Reported fusion rates are not frequently supported by adequate information regarding by whom and how fusion was defined. In our prospective study we examined the fusion rate in patients undergoing first time anterior cervical discectomy and fusion for degenerative disease. Separate, well-defined radiographic fusion criteria were used and the 12-month post-operative X-rays were reviewed independently by a neurosurgeon, a neuroradiologist and an orthopedic surgeon, who were not involved in the patients' management. The observed fusion rates were 77.3, 87.8 and 84.7% respectively. Statistical analysis demonstrated concordance rates of 87.8, 91 and 91.4% and Kappa coefficients of 0.585, 0.620 and 0.723 for each pair of evaluators. Another set of ratings of the same radiographs, by the same interviewers, was obtained 6 weeks after the initial one. The reported fusion rates were 78.2% for the neurosurgeon, 87.4% for the orthopedic surgeon, and 86.1% for the neuroradiologist. Statistical analysis demonstrated intra-observer concordance rates of 98.7, 92.2 and 97.9% respectively, while the Kappa coefficients were 0.963, 0.677 and 0.907 for each reviewer. Our findings confirm the necessity of defining and describing criteria for fusion whenever this rate is reported in clinical series. The lack of widely accepted, well-defined criteria makes comparison of these results difficult. The development of a well organized, prospective clinical study in which fusion and outcome will be assessed by both clinical and radiographic parameters could significantly contribute to a more accurate evaluation of overall outcome of cervical spinal procedures.

An ultrasonic method was used to non-invasively measure intracranial blood volume (IBV) pulse waveforms. This technology has previously shown a strong association between invasively recorded ICP pulse waves and non-invasively recorded IBV pulse waves. The objective of the present study was to investigate the diagnostic value of non-invasively measured IBV pulse waves in the cases of different pathologies. A total of 75 patients were examined and these included cases of acute, chronic and stabilized hydrocephalus, spinal cord injury and terminal blood flow. These were compared to a control group of 53 healthy volunteers. The object of comparison was normalized and averaged IBV pulse waves. Pathological IBV pulse waveforms were compared with IBV pulse waveforms of the normal group using sub-wave values, the area under waveform curve and the Euclidean distance calculation. The non-invasively measured IBV pulse waveform is not significantly dependent on acoustic path, gender or age. A detectable change in IBV pulse waveform shape was observed in situations when disturbance in intracranial hydrodynamics was present, e.g. during hypoventilation tests, in cases of terminal blood flow and hydrocephaly, depicting the level of hydrocephalus activity and the patient's compensatory capabilities as well as the effect of treatment.

The association of third cranial nerve palsy subsequent to an enlarging posterior communicating artery (P-Com A) aneurysm has been well described. In our current communication, we review the relevant literature and propose a classification system for the severity of the third cranial nerve palsy, correlating it to the postoperative recovery. Our four grade scale (I-IV) included the degree of the levator palpebrae muscle paresis, the presence of pupillary reaction and the impairment of the third nerve mediated extraocular muscle movement. We evaluated five patients with third nerve palsy secondary to non-ruptured, P-Com A aneurysm. Patients were re-evaluated at 2, 4, 8, 24 weeks postoperatively. Four of the five patients had complete recovery within 4-8 weeks after surgery. One patient had grade II third nerve paresis and complete resolution of the third nerve symptoms within 4 weeks, whereas three patients with grade III and IV had complete resolution 4-8 weeks after surgery. The fifth patient, with grade IV paresis, had minimal (grade III) improvement 6 weeks after surgery, and incomplete recovery (grade I) 6 months postoperatively. Our simple grading system of third nerve palsy associated with P-Com A aneurysms, can be a helpful tool for the initial evaluation and for the monitoring of recovery in these patients.

Study design Retrospective analysis of the fusion rate of a group of 38 patients having undergone anterior screw fixation for type II and "shallow" type III odontoid fractures. OBJECTIVE.: To determine primarily the long-term fusion rate after anterior screw fixation and to study the clinical characteristics of patients that have a statistically significant or nonsignificant influence on successful outcome. Summary of background data Long-term outcome of anterior screw fixation for odontoid fractures has been evaluated in very few studies. This information should be critical for further establishing this technique as a major therapeutic strategy for these cases. Methods Thirty-eight patients, 25 males and 13 females (with mean age 48.4 +/- 0.4 years), with type II and rostral type III odontoid fractures, underwent anterior cannulated screw fixation during a 62-month period. Radiologic examination of the cervical spine with plain radiographs was performed at 6 weeks, and 2, 6, 12, and 24 months, while computerized tomography of the upper cervical spine (C1-C3) was obtained at 6 months after surgery. Follow-up was available for 31 patients, and the follow-up time ranged from 39 to 87 months (mean 58.4). Results Radiographic evaluation of the follow-up group showed satisfactory bony fusion and no evidence of abnormal movement at the fracture site in 27 (87.1%) patients. Pseudarthrosis developed in 4 (12.9%) patients; however, 3 (9.6%) of them without instability and 1 (3.2%) with instability. One (3.2%) patient had an instrumentation failure without instability. Conclusions In our series, anterior odontoid screw fixation comprised a safe therapeutic modality with high stability and low mechanical failure rates during short-term and long-term follow-up.

OBJECTIVES The atlantoaxial segment of the cervical spine is commonly destabilized in a variety of disorders. Transarticular screw fixation of the C1-C2 joint has been proposed as a biomechanically superior therapeutic modality. The authors present their experience with this technique. METHODS A retrospective analysis of 23 patients treated with this technique was performed. The mean follow-up period was 39.5 +/- 0.1 months. RESULTS Mean duration of hospitalization was 3.4 +/- 0.1 days (range, 2 to 11 days). No intraoperative or early postoperative complications were detected. Four patients (17.4%) had postoperative complications unrelated to the primary procedure. The position of the screw was judged as satisfactory in 21 patients (91.3%). Two patients (8.7%) with suboptimal positioning of the screws were neurologically intact but needed no reoperation. Solid osseous fusion was detected in 19 patients (82.6%). CONCLUSIONS Transarticular C1-C2 screw fixation appears to be a safe and surgically reliable technique. Criteria for its application and refinements in its technical considerations continue to advance its clinically versatile therapeutic potential.

This case report presents a newborn baby girl, who was diagnosed at birth with a mid-cervical meningocele. Further radiographic workup by MRI revealed co-existing thoracic diplomyelia and bilateral tethered cords. At birth the patient was found to be neurologically intact. Surgery was performed at 4 months of age, the patient undergoing simultaneous repair of the cervical meningocele, exploration of the diplomyelia, and release of the tethered cords bilaterally. Long-term follow-up revealed an ambulating patient with no bowel or bladder incontinence, who has developed well for her chronological age so far.A review of the literature relevant to this case is also presented.

Introduction: The wide use of intracranial pressure and cerebral perfusion pressure monitoring has improved the management of patients with severe head injuries. The rare but worrying complications associated with the application of such monitoring makes the idea of a non-invasive method of monitoring very attractive. Materials and methods: A new non-invasive ultrasonographic technology was used to measure cerebral perfusion pressure in 27 normal volunteers. The average monitoring time was 45.3±0.2 min, and the average perfusion pressure recorded was 77.4±0.3 mmHg. No complications were reported during the procedure, which was performed while the subjects were in regular ward beds. Conclusion: The non-invasive character of this method could extend the use of cerebral perfusion pressure measurement to several other neurosurgical entities, such as hydrocephalus, pseudotumor cerebri, chronic headache, and spinal cord injuries.

Objective The diversion of cerebrospinal fluid (CSF) has been widely used in the prevention and treatment of CSF fistulae. A common method is the use of a lumbar drainage system. Although it is effective, several serious complications can develop, which can be avoided by regulating the flow of CSF with a standard intravenous infusion pump. Technique We present a simple, inexpensive, and accurate method of flow-controlled lumbar subarachnoid drainage that minimizes patient discomfort and the unpredictability of a gravity-dependent system. This system uses a standard lumbar drain connected to an intravenous infusion pump to provide drainage of CSF in a constant and predictable manner. Results A total of 42 patients from two institutions were treated with this method. CSF fistulae occurred secondary to trauma in 9 patients, after spinal surgery in 11 patients, after transsphenoidal surgery in 10 patients, and after cranial base surgery in 12 patients. Resolution of the fistula was attained in 36 of 42 patients. There were no deaths, no cases of deep venous thrombosis, and no incidence of meningitis. One patient developed tension pneumocephalus, and two patients developed headache with nausea and vomiting. All patients were ambulatory, and only three patients required narcotic analgesia for headaches. Conclusion Pump-regulated lumbar subarachnoid drainage is safe and effective in the treatment of CSF fistulae, as reported elsewhere in the literature. The advantage of this method is that the drainage of CSF can be carefully controlled and titrated in a predictable fashion. Because the system is independent of gravity to produce drainage of CSF, patients are not confined to bed and serious complications of overdrainage can be avoided.

Study Design. One hundred two patients with symptoms of cervical radiculopathy, were retrospectively analyzed and their cervical spinal cord diameters obtained. Objectives. To measure the cervical spinal cord in vivo and to compare the findings with those previously reported in the literature. Summary of Background Data. Traditionally, autopsy data have served as the linchpin of cervical cord measurements. However, several studies obtained by realtime radiographic methods have failed to confirm such measurements. Methods. The spinal cord was retrospectively measured in 102 patients. All patients underwent myelogram and postmyelogram computed tomographic scan. Anteroposterior and transverse diameters of the spinal cord were measured from C2 to T1 at the level of each intervertebral disc. The depth of the anterior median fissure and cross-sectional area were measured as well. Plain myelographic films were reviewed but demonstrated no findings contrary to postmyelogram computed tomographic measurements. Results. There was no statistically significant difference in the spinal cord measurements in relation to age or sex. There was an increase in the transverse diameter but not in the anteroposterior diameter in the midcervical spinal enlargement. The anteroposterior diameter decreased linearly. The transverse diameter and the cross-sectional area increased to a maximum at C5, as did the depth of the anterior median fissure. The cervical spinal cord diameter was documented to be 15-20% smaller than has commonly been determined by autopsy data. Conclusions. Postmyelogram computed tomographic measurements are smaller than those obtained from autopsy data.

We present a series of 21 patients, 12 males and 9 females, aged 41–76 years, with the preoperative diagnosis of a brain tumor. Both preoperatively and postoperatively, all of our patients underwent either a brain computed tomography (CT) or magnetic resonance imaging (MRI). All the radiographic studies were taped and loaded preoperatively in the Stereotactic Microscopic Navigator (SMN) workstation (Zeiss, Germany). The mean duration of this procedure was 25 ± 6 min. All our patients were operated on in our institute with the use of the SMN system. The specificity of tumor localization using CT scan was 2.20 ± 0.25 mm and for the MRI scan 2.6 ± 0.25 mm. As assessed by postoperative radiographic studies, total gross tumor resection was possible in 20 patients (95.23%). No major intraoperative or early postoperative complications were noted in our series. We believe that the SMN system is a safe, well-tolerated by the patients and simple method with extremely high accuracy and specificity.

Postoperative fever is a common sequel of spine surgery. In the presence of rigid nationally mandated clinical guidelines, fever management may consume more health care resources than is reasonably appropriate.To study the relationship between postoperative fever, infection rate, and hospital charges in a cohort of spine surgery patients.We retrospectively reviewed 578 spine surgery patients (lumbar microdiskectomy [LMD], anterior cervical decompression and fusion [ACDF], and lumbar decompression and fusion [LDF]). Differences in length of stay and hospital charges as well as risk factors and correlation with infection and readmission rates were studied.Postoperative fever occurred in 41.7% of all spine surgery patients and more often in LDF patients (77.2%). Type of surgery was the most important variable affecting the prevalence of postoperative fever. Significant differences in length of stay were elicited between patients with and without postoperative fever in the ACDF and LMD groups and in hospital cost in the LMD group. The average length of stay was 2.41 vs 4.47 (P.01) in the LMD group, 1.67 vs 2.80 (P.05) in the ACDF group, and 5.03 vs 5.65 (P.05) in the LDF group. The average hospital charges were $16 261 vs $22 166 (P.01) in the LMD group, $26 021 vs $29 125 (P.05) in the ACDF group, and $53 627 vs $53 210 (P.05) in the LDF group. Obesity, female sex, and ≥102°F postoperative temperature were the most significant predictors of infection. Delayed discharge referable to postoperative fever did not seem to influence the infection readmission rate.Postoperative fever in spine surgery patients is associated with a delay in patient discharge and increases in hospital charges. Postoperative fever discharge guidelines should be regularly and publicly subjected to appropriate cost-benefit analysis.

Comorbidities in patients undergoing spine surgery may reasonably be factors that increase health care costs. To verify this hypothesis, the authors conducted the following study.Major comorbidities and age-adjusted Charlson Comorbidity Index scores were retrospectively analyzed for 816 patients who underwent spine surgery at the authors' institutions between 2005 and 2008, and treatment costs (hospital charges) were assessed with the help of statistical software. The sample was collected by a nonmedical staff (hired at the beginning of 2006). Patients underwent one of the three most common types of spine surgery: lumbar microdiscectomy (20.5%), anterior cervical decompression and fusion (ACDF; 60.3%), or lumbar decompression and fusion (LDF; 19.2%). Patients were nearly equally divided by sex (53% were female and 47% male), and 78% were Caucasian versus 21% who were African American; the rest were of mixed or unidentified race. The average age was 54 years, with an SD of ± 14 years.There were significant differences in the prevalence of major comorbidities between male and female and between severely obese and nonseverely obese patients. The impact of comorbidities on the cost of spine surgery was more prominent in older patients, and an additive effect from some comorbidities was recorded in various types of spine surgery. For instance, in the ACDF group, female patients with both severe obesity and diabetes mellitus (DM) had significantly higher hospital charges than those with only one or neither of these conditions ($34,943 for both severe obesity and DM vs $25,633 for severe obesity only; $25,826 for DM only; and $25,153 for those with neither condition [p0.05]). In the LDF group, female patients with both DM and a history of depression had significantly higher hospital charges than those with only one or neither of these conditions ($65,782 for both DM and depression vs $53,504 for DM only; $55,990 for depression only; and $52,249 for those with neither condition [p0.05]). A significant difference was also found in hospital cost ($16,472 [p0.01]; 32% increase over baseline) in the LDF group between patients with the lowest and highest scores on the Charlson Index.Comorbidities additively increase hospital costs for patients who undergo spine surgery, and should be considered in payment arrangements.

Objective To study the role of drains in lumbar spine fusions. Methods The charts of 402 patients who underwent lumbar decompression and fusion (LDF) were retrospectively reviewed. Patients were classified per International Classification of Diseases, 9th Edition (ICD-9) procedure code as 81.07 (lateral fusion, 74.9%) and 81.08 (posterior fusion, 25.1%). The investigators studied the prevalence of drain use in lumbar fusion procedures and the impact of drain use on postoperative fever, wound infection, posthemorrhagic anemia, blood transfusion, and hospital cost. Results No significant differences in wound infection rates were noted between patients with and without drains (3.5% vs 2.6%, P = 0.627). The difference in postoperative fever rates between patients with and without drains (63.2% vs 52.6%, P = 0.05) was of borderline significance. Posthemorrhagic anemia was statistically more common in patients with drains (23.5% vs 7.7%, P = 0.000). Allogeneic blood transfusion was also statistically more common in the drained group (23.9% vs 6.8%, P = 0.000). Postoperative hemoglobin levels were lower in patients with drains who underwent one-level (9.5 g/dL vs 11.3 g/dL) or two-level (9.3 g/dL vs 10.2 g/dL) spine fusions. In this series in which drains were liberally used, no patient had to return to the operating room because of postoperative hematoma. An increased rate of allogeneic blood transfusion was noticed with posthemorrhagic anemia and drain use. The rate of allogeneic blood transfusion increased from 5.6% in patients without drains or posthemorrhagic anemia to 38.8% in patients with drains and posthemorrhagic anemia as a secondary diagnosis. The use of drains was associated with statistically insignificant increases in length of stay and cost in posterior procedures. Drain use was associated with shorter length of stay and hospital charges in lateral fusions of three or more levels. Conclusions Drain use did not increase the risk of wound infection in patients undergoing LDF, but it had some impact on the prevalence of postoperative fever. Drain use was significantly associated with posthemorrhagic anemia and allogeneic blood transfusion. Drain use did not have a significant economic impact on hospital length of stay and charges except in lateral procedures involving three or more levels.

Elevated levels of glycosylated hemoglobin (HbA1c) among spine surgery patients may have an impact on length of stay (LOS) and healthcare cost.We retrospectively reviewed the charts of 556 spine surgery patients who underwent 1 of 3 types of surgery: lumbar microdiscectomy (LMD), anterior cervical decompression and fusion (ACDF), and lumbar decompression and fusion (LDF). Information was collected about their diabetes mellitus (DM) history and HbA1c levels. We used HbA1c 6.1% as the screening cutpoint. Percentages of nondiabetic patients, those with subclinical elevation of HbA1c and those with already known DM were calculated and statistical analysis was applied.After excluding the small group of well-controlled DM (n = 14), 72.4% of patients were nondiabetic, 14.3% were subclinical patients with previously unknown HbA1c elevation, and 13.3% were already known, confirmed DM patients. There were significant differences in the LDF group between the "No DM" and "Subclinical" groups (P0.05) in terms of cost and LOS (P0.05). Age and body mass index (BMI) were very significant predictors of total cost in spine surgery patients (Por= 0.001), in addition to the type of surgery. Univariate analysis with age, BMI, or both as covariates deprived DM-HbA1c status of statistical significance (P0.05) in determining cost.There is a significant segment of spine surgery patients who were unaware of their elevated HbA1c status before their preoperative visit. These patients seem to utilize more healthcare resources, which is especially evident in the LDF group. We believe that HbA1c should be considered in the routine preoperative workup of spine surgery patients.

Object Cerebral vasospasm is a common and potentially devastating complication of aneurysmal subarachnoid hemorrhage (aSAH). Inflammatory processes seem to play a major role in the pathogenesis of vasospasm. The Creactive protein (CRP) constitutes a highly sensitive inflammatory marker. The association of elevated systemic CRP and coronary vasospasm has been well established. Additionally, elevation of the serum CRP levels has been demonstrated in patients with aSAH. The purpose of the current study was to evaluate the possible relationship between elevated CRP levels in the serum and CSF and the development of vasospasm in patients with aSAH. Methods . A total of 41 adult patients in whom aSAH was diagnosed were included in the study. Their demographics, the admitting Glasgow Coma Scale (GCS) score, Hunt and Hess grade, Fisher grade, CT scans, digital subtraction angiography studies, and daily neurological examinations were recorded. Serial serum and CSF CRP measurements were obtained on Days 0, 1, 2, 3, 5, 7, and 9. All patients underwent either surgical or endovascular treatment within 48 hours of their admission. The outcome was evaluated using the Glasgow Outcome Scale and the modified Rankin Scale. Results The CRP levels in serum and CSF peaked on the 3rd postadmission day, and the CRP levels in CSF were always higher than the serum levels. Patients with lower admission GCS scores and higher Hunt and Hess and Fisher grades had statistically significantly higher levels of CRP in serum and CSF. Patients with angiographic vasospasm had higher CRP measurements in serum and CSF, in a statistically significant fashion (p < 0.0001). Additionally, patients with higher CRP levels in serum and CSF had less favorable outcome in this cohort. Conclusions Patients with aSAH who had high Hunt and Hess and Fisher grades and low GCS scores showed elevated CRP levels in their CSF and serum. Furthermore, patients developing angiographically proven vasospasm demonstrated significantly elevated CRP levels in serum and CSF, and increased CRP measurements were strongly associated with poor clinical outcome in this cohort.

A 49-year-old white female presented to the emergency room complaining of severe headaches. A brain computed tomography (CT) showed a large right temporal mass that measured 2.9 x 5 cm. Sodium was low at admission, which indicated syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Her pituitary gland was enlarged. Thorax CT revealed a large anterior mediastinal mass measuring 6.3 x 3.6 cm. Pathology revealed a poorly differentiated carcinoma arising from the thymus. This case is unique because thymic cancer rarely results in brain metastases and very rarely causes SIADH with changes in pituitary volume and signal quality.

Objective: We addressed the prevalence of opioid dependence (OD) in spine surgery patients and its correlation with length of stay (LOS) as the most important determinant of hospital cost.Methods: The study took place at Georgia Neurosurgical Institute and the Medical Center of Central Georgia between March 2006 and January 2007. A prospective convenience sample of 150 spine surgery patients (48 lumbar diskectomy, 60 cervical decompression and fusion, and 42 lumbar decompression and fusion [LDF]) was assembled. Patients were interviewed before surgery using a questionnaire designed in accordance with the World Health Organization and DSM-IV-TR criteria for the diagnosis of OD. The prevalence of OD was calculated based on questionnaire results. Pain intensity was quantified during admission using a 0-to-10 pain scale. We used pain intensity multiplied by duration of pain in months (WR index) as a new parameter. Lengths of stay were collected following patients’ discharge from hospital. Pearson correlation and regression analysis were performed using SPSS software.Results: Thirty (20.00 percent) patients were opioid dependent. The prevalence was highest among LDF patients (23.81 percent), females (22.78 percent), and, to a lesser degree, Caucasians (20.87percent). There was no correlation between OD and age (r = 0.08, p > 0.1) or between OD and LOS (r = 0.09, p > 0.1). This study proved a very significant positive correlation between OD and pain intensity (r = 0.24, p < 0.01) and between OD and the WR index (r = 0.30, p < 01). On the other hand, there was a significant positive correlation between LOS and age(r= 0.42, p < 0.01), between LOS and the number of previous spine surgeries (r = 0.28, p < 01), and between LOS and duration of pain (r = 0.18, p < 0.05). Regression analysis showed that age, ethnicity, and type of surgery were the main determinants of LOS.Conclusions: Chronic pain and prolonged use of opioids raise the prevalence of OD in spine surgery patients to 20 percent. The lack of effect of OD on LOS after surgical intervention means that efforts to decrease LOS by trying to satisfy patients’ craving for opioids will not be fruitful. Older, African-American LDF patients with a lengthy history of pain and multiple spine surgeries in the past are the most likely to stay longer in hospital.

Study design Retrospective review study with literature review. Objective The goal of our current study is to raise awareness on complications associated with anterior cervical discectomy and fusion (ACDF) and their early detection and proper management. Summary of background data It is known that ACDF constitutes one of the most commonly performed spinal procedures. Its outcome is quite satisfactory in the majority of cases. However, occasional complications can become troublesome, and in rare circumstances, catastrophic. Although there are several case reports describing such complications, their rate of occurrence is generally underreported, and data regarding their exact incidence in large clinical series are lacking. Meticulous knowledge of potential intraoperative and postoperative ACDF-related complications is of paramount importance so as to avoid them whenever possible, as well as to successfully and safely manage them when they are inevitable. Methods In a retrospective study, 1015 patients undergoing first-time ACDF for cervical radiculopathy and/or myelopathy due to degenerative disc disease and/or cervical spondylosis were evaluated. A standard Smith-Robinson approach was used in all our patients, while an autologous or allograft was used, with or without a plate. Operative reports, hospital and outpatient clinic charts, and radiographic studies were reviewed for procedure-related complications. Mean follow-up time was 26.4 months. Results The mortality rate in our current series was 0.1% (1 of 1015 patients, death occurred secondary to an esophageal perforation). Our overall morbidity rate was 19.3% (196 of 1015 patients). The most common complication was the development of isolated postoperative dysphagia, which observed in 9.5% of our patients. Postoperative hematoma occurred in 5.6%, but required surgical intervention in only 2.4% of our cases. Symptomatic recurrent laryngeal nerve palsy occurred in 3.1% of our cases. Dural penetration occurred in 0.5%, esophageal perforation in 0.3%, worsening of preexisting myelopathy in 0.2%, Horner's syndrome in 0.1%, instrumentation backout in 0.1%, and superficial wound infection in 0.1% of our cases. Conclusion Meticulous knowledge of the ACDF-associated complications allows for their proper management. Postoperative dysphagia, hematoma, and recurrent laryngeal nerve palsy were the most common complications in our series. Management of complications was successful in the vast majority of our cases.

Acute cranial subdural hematoma (SDH) represents a common consequence of traumatic brain injury. The vast majority of acute SDHs larger than 10 mm in thickness require immediate surgical evacuation. In rare occasions, however, spontaneous resolution may occur. In our current communication, we present four cases of spontaneous resolution of acute cranial SDH. Further more, the proposed theories explaining spontaneous resolution of acute SDH, as well as, clinical parameters and imaging characteristics that might predict such phenomenon, are also reviewed. The possibility of spontaneous resolution of an acute SDH, although remote, may impact the decision making process regarding the management of these patients under certain conditions.

Objective Ventriculoatrial (VA) shunts remain a valid option for the treatment of hydrocephalus, especially in patients in whom ventriculoperitoneal (VP) shunts fail. Correct positioning of the distal end of the catheter in the right atrium is of paramount importance for maintaining shunt patency and reducing the incidence of VA shunt-associated morbidity. The authors present their experience with real-time transesophageal echocardiography (TEE) monitoring for the accurate placement of the distal catheter of a VA shunt. Methods Four patients underwent conversion of a VP shunt to a VA shunt under the guidance of intraoperative fluoroscopy and TEE between May 2003 and December 2004. After induction of general anesthesia, the TEE transducer was advanced into the esophagus. A cervical incision was made and the external jugular vein was visualized. An introducer was passed through an opening in the jugular vein and a guidewire was placed through the introducer. Under continuous TEE guidance, the guidewire was carefully advanced into the superior vena cava. A distal shunt catheter overlying a J-wire was then passed to the superior vena cava, again under TEE guidance. The catheter was advanced to the right atrium after removing the guidewire. Final visualization with TEE and fluoroscopy revealed a good position of the catheter in the right atrium in all four cases. The mean duration of the operation was 91 minutes (range 65–120 minutes) and the mean operative blood loss was 23 ml (range 10–50 ml). No procedure-related complication was noted. Conclusions Real-time TEE is a safe and simple technique for the accurate placement of the distal catheter of a VA shunt.

Introduction: Kyphoplasty, a minimally invasive technique, has recently been developed to provide immediate pain relief, biomechanical stabilization, prevention of fracture progression, vertebral height restoration, and prevention or reversal of kyphosis to patients with osteoporotic vertebral compression fractures (VCF). Materials and Methods: We retrospectively reviewed 24 patients treated with kyphoplasty. A total of 37 vertebral levels were augmented. Visual analog scale (VAS) scores were documented in the immediate pre- and postoperative period, as well as 4, 12, and 72 weeks after the procedure. Vertebral body height restoration was assessed on postoperative x-rays. Results: Mean preoperative VAS score was 9.3 and improved to 5.4 in the immediate postoperative period. At 4, 12 and 72 weeks postoperatively, mean VAS scores were 5.1, 5.9, and 6.1 respectively. All patients returned to their daily activities within 24 hours. No significant restoration of vertebral body height was observed. Conclusion: In regards to pain relief and postoperative functional outcome, kyphoplasty is a safe and effective treatment modality for osteoporotic VCFs, even when no significant restoration of vertebral body height is achieved.

✓ Pediatric spinal epidural hematoma is a very rare clinicopathological entity. In the vast majority of cases, spinal epidural hematomas have a nonspecific clinical presentation; this, along with their rapid progression, makes their early diagnosis and prompt surgical evacuation critical. Magnetic resonance imaging is the neuroimaging modality of choice, whereas hemilaminectomy or laminectomy is the indicated surgical intervention. The outcome is good when hematoma evacuation is performed before the onset of complete sensorimotor paralysis. In this communication, the authors describe a 12-year-old girl with a traumatic acute cervical epidural hematoma. This lesion was successfully evacuated through a hemilaminectomy, and the patient had an excellent outcome. The pertinent literature is reviewed in terms of the incidence, origin, management, and prognosis of this rare and potentially disastrous clinical entity.

Familial cases of intracranial ependymomas have been well documented in the literature. The authors present two cases from a family in which three members harbored intracranial ependymomas. A 54-year-old man with fourth ventricular ependymoma underwent resection of the tumor followed by radiation therapy. His son presented at age 36 years with a fourth ventricular tanycytic ependymoma and underwent total resection of the ependymoma with postoperative radiation therapy. The father's sister had been treated at another institution for a posterior fossa ependymoma. The association of ependymomas with molecular genetic alterations in chromosome 22 has been previously described. Further investigation of the genetic influences may lead to better therapeutic approaches for this relatively rare clinicopathological entity.

Objectives In the present study, the authors comment on their experience with anterior odontoid screw fixation in the management of odontoid fractures, in an attempt to further assess the safety and the efficacy of this procedure. Materials and methods A retrospective analysis of 50 consecutive patients with reducible type II or rostral type III odontoid fractures, operated at our hospital with anterior odontoid screw fixation. Radiographic bony fusion, complications, and clinical outcome were evaluated. Results Solid bony fusion was evident in 38 (90.5%) of the patients. One mechanical instrumentation-related complication occurred, without clinical significance. No other major complications related to the procedure were noted. A satisfactory range of motion in the cervical spine was observed in all patients. Conclusions Anterior odontoid screw fixation is a safe and effective procedure for the treatment of type II and rostral type III odontoid fractures. Compliance to the specific indications and contraindications of this operation is crucial for optimal outcome.

INTRODUCTION Accurate knowledge of cerebral temperature is assuming increasing importance, because its manipulation is employed more frequently for cerebral protection. PURPOSE This prospective clinical study was performed to examine how well intraventricular temperature reflects global cerebral temperature. METHODS The intraventricular temperature was monitored in 61 patients who were admitted to the neurointensive care unit for various intracranial pathological entities. A temperature probe coupled to an intraventricular pressure monitor was inserted in the lateral ventricle. At the conclusion of the monitoring process, a second intraventricular temperature probe was inserted in the ipsilateral ventricle and the previous one was carefully and gradually removed. During that removal, the intraparenchymal temperature was monitored for 90 minutes at 1-cm intervals throughout the brain parenchyma. RESULTS The mean intraventricular temperature was 37.84+/-1.03 degrees C, whereas the mean systemic (rectal) temperature was 37.65+/-0.68 degrees C. At 1 cm outward distance from the lateral ventricle, the mean intraparenchymal temperature was 38.21+/-0.32 degrees C, 38.39+/-0.33 degrees C at 2 cm, 38.27+/-0.31 degrees C at 3 cm, 38.26+/-0.29 degrees C at 4 cm, and, finally, 37.9+/-0.50 degrees C at 5 cm. Statistical analysis of the recordings showed no statistically significant differences between the intraventricular and intraparenchymal temperatures and intraventricular and rectal temperatures. No statistically significant correlation was established between the intraventricular temperature and parameters, such as the patient's age, sex, and admitting diagnosis. CONCLUSION Cerebral temperature was relatively stable through the brain parenchyma in this study. Because intraventricular temperature accurate.

Golf-related head injuries constitute an increasingly common mechanism of head trauma in children. We present our experience with 33 pediatric cases of golf-associated head injury, with special emphasis in the type of injury, management strategy, and outcome.A thorough review of all children admitted to our hospital with golf-related head injury during a period of 10 years (1 January 1994 to 31 December 2003) was undertaken. The patients' charts, operative reports, imaging studies, and follow-up data were analyzed. A comparison of our findings with those described in the pertinent literature was subsequently performed.Pediatric golf-related head trauma is a significant cause of sport-associated head injury, sometimes harboring a very dismal prognosis. The significance of establishing a task force for the prevention of these injuries cannot be overemphasized.

Object Painful osteoporotic vertebral compression fractures (VCFs) are a significant cause of disability in the elderly population. Kyphoplasty, a recently developed minimally invasive procedure, has been advocated for the successful management of these fractures in terms of immediate pain relief, and also for restoration of the premorbid level of daily activities. In this retrospective study the authors report on their experience with the early management of VCFs with kyphoplasty. Methods A retrospective analysis was conducted in 13 patients (seven women and six men) whose ages ranged from 48 to 87 years (mean age 71.5 ± 11 years [mean ± standard deviation]). The interval between onset of symptoms and surgical intervention ranged from 4 to 9 weeks. Twenty levels (12 thoracic, eight lumbar) were treated in this cohort. Immediate and early postoperative (1-month follow-up visit) visual analog scale (VAS) pain scores, activity levels, and restoration of vertebral body (VB) height were assessed. The mean preoperative VAS score was 8 ± 1, whereas the immediate and early postoperative scores were 1 ± 1. These findings reflected a resolution of 90 to 100% of preoperative pain. All patients resumed routine activities within hours of the procedure, although improvement in VB height was not accomplished in this cohort. No major complications were encountered in this clinical series. Conclusions Kyphoplasty is a safe and effective method for the treatment of osteoporotic VCFs. Failure to restore VB height does not seem to interfere with the excellent pain management and good functional outcome provided by this procedure.

Hemangiopericytomas represent rare intracranial tumors that have a tendency to recur locally and have the unique characteristic of giving extracranial metastases. Our current communication reviews a series of patients diagnosed with hemangiopericytoma who were treated in our facility. Eleven patients with a mean age of 51.2 years underwent follow-up for a mean time of 7.1 years. Their neuroimaging preoperative evaluation included plain skull X-rays, head CT scans, brain MRI, angiograms, and (1)HMRS. Preoperative embolization of the tumor was employed in 6/11 patients. All patients underwent craniotomy for tumor resection and postoperative radiation treatment was employed on all but one. Grade I resection was accomplished in 6/11 (54.5%), grade III in 4/11 (36.4%), and grade IV in 1/11 (9.1%). Local recurrence was detected in 3/11 (27.3%) at a mean period of 5 (range 2-7.5) years. Extracranial metastatic disease was documented in 4/11 (36.4%) patients at a mean of 4.9 (range 2.5-7) years after the initial diagnosis. The GOS score was: 7/11 (63.6%) scored 5, while 4/11 (36.4%) died at a mean time of 5.5 (range 3-8) years after the initial diagnosis. Intracranial hemangiopericytomas management requires aggressive surgical resection, postoperative radiation treatment, and extensive follow-up to rule out local recurrences and delayed extracranial metastases.

Background. Cerebral hydatid cysts account for up to 3.6% of all intracranial space-occupying lesions, in endemic countries. The vast majority of patients affected are children. Computed tomography (CT) and magnetic resonance imaging (MRI) have greatly contributed to a more accurate diagnosis of hydatids. However, correct pre-operative diagnosis still remains quite puzzling. Extirpation of the intact cyst is the treatment of choice, resulting in most cases to a complete recovery. Method. In our retrospective study, we have reviewed 76 cases of intra-cranial hydatid disease operated on in our hospital over a 22 year period. Presenting clinical symptoms and signs and the radiological findings on CT and MRI were documented. Albendazole was given preoperatively to patients with giant (>5 cm) or multiple cysts and postoperatively to all patients. The follow-up period ranged from 12 months to 22 years and the outcome was assessed using the Glasgow Outcome Scale (GOS). Findings. Sixty seven (95.7%) of our patients were children. Increased intracranial pressure and papilledema were the predominant findings in this group, whereas focal neurological deficits were most prevalent in adults. CT and MRI revealed round cystic lesions, isodense and iso-intense respectively to cerebrospinal fluid (CSF), with no rim enhancement or perifocal edema. Multiple cysts were identified in 3 cases. Extirpation of the cyst without rupture was accomplished in 56 patients (73.7%). Recurrences occurred in 19 patients (25%). 4 patients (5.3%) died within 6 months after surgery; 3 of these patients had multiple cysts and one died shortly after the operation due to anaphylactic shock following intra-operative rupture of the cyst. Conclusion. Long-term follow-up confirms that intracranial hydatid cysts should always be surgically removed without rupture; the outcome remains excellent in these cases. Correct preoperative diagnosis is vital for the successful outcome of surgery. A high index of suspicion is therefore required in endemic areas despite the availability of advanced neuro-imaging. Medical treatment with albendazole seems to be beneficial both pre- and post-operatively. Newer diagnostic methodologies, such as MR spectroscopy and MR diffusion weighted imaging, might lend themselves to the diagnosis of intracranial hydatid cysts.

Study design The authors conducted a prospective clinical study. Objectives The objectives of this study were to investigate the relationship, if any, of the amount of removed disc in a standard first-time lumbar microdiscectomy and long-term outcome as well as recurrence and postoperative instability rates. Summary of background data There is lack of data on the amount of disc that needs to be removed during a lumbar microdiscectomy. Anecdotal data and dogmatic recommendations make the subject even more controversial. Material and methods A total of 106 patients underwent a standard first-time lumbar microdiscectomy for medically refractory sciatica resulting from a herniated disc. The removed disc material was weighted. All patients were clinically followed for at least 2 years and outcome was evaluated by using pain intensity, presence of physical signs, functional capacity, return to work, and patients' opinion regarding their outcome. Results The mean amount of disc removed was calculated at 2.1 +/- 0.9 g. Ninety-one patients had an excellent outcome and returned to their preoperative work. Fifteen patients had persistent symptomatology and underwent extensive radiographic workup, which revealed a disc recurrence at the same level in 8 patients and first-degree instability in 3 patients. In the remaining 4 patients, no clinical or radiographic abnormality was proven and the patients were treated conservatively, whereas all of them had applied for disability. No relationship was proven between the amount of the removed disc and the intraoperative blood loss or the intraoperative complication rate. Our statistical analysis showed no correlation between the amount of the removed disc and the long- term outcome, recurrence rate, or postoperative instability. Conclusions The degree of disc removal did not influence the outcome or complication rate in our clinical series.

Our objective was to correlate the findings of intraoperative electromyographic (EMG) monitoring with immediate postoperative pain in patients undergoing lumbar microdiscectomy.A total of 112 patients undergoing de novo lumbar microdiscectomy were prospectively randomized into a control group (n = 45) and a study group (n = 67) in which intraoperative EMG monitoring was used. Postoperative pain and postoperative narcotic consumption were recorded for each patient.The presence or absence of EMG monitoring did not influence the level of reported pain in any anatomic area. In the monitored group, the degree of recorded nerve root irritation did not correlate with reported pain or postoperative narcotic consumption. The level of back pain was found to be significantly higher than the level of hip and calf pain (P0.0001).In our study no correlation was found between intraoperative EMG findings and immediate postoperative pain.

Background: Proton magnetic resonance spectroscopy (1H MRS) constitutes a promising modality to assess intracranial pathology. We present our experience using this method in grading solid brain astrocytomas. Material and Methods: Using a 1.5-Tesla MRI unit, 71 patients with the radiographic diagnosis of astrocytoma were examined. Water-suppressed single-voxel 1H MRS was employed in all of our patients. The concentrations of choline (Cho), N-acetyl-aspartate (NAA), phosphocreatine-creatine (Pcr-Cr), myo-inositol (MI), lactate (Lac), lipids (Lip) as well as the metabolite ratios of Cho/Pcr-Cr, NAA/PCr-Cr and NAA/Cho were calculated. An appropriate surgical biopsy was performed. Standard pathology examination was employed in a double-blinded fashion. Results: An increased concentration of Cho and decreased concentrations of Pcr-Cr and NAA were detected. The concentrations of Lac, Lip and MI varied inconsistently, even among tumors of the same histologic grade. The Cho/Pcr-Cr ratio was calculated. This ratio was found to be 2.15 ± 0.26 in 27 patients with astrocytomas grade I and II, 2.78 ± 0.09 in 18 patients with grade III, and 5.40 ± 0.16 in 26 patients with grade IV. Discussion: The increased concentration of Cho is due to the increased cellularity and a relatively increased number of membranous structures in highly malignant tumors. In abnormal anaerobic metabolic tumor states there is relatively less phosphorylization of creatine. By using the Cho/Pcr-Cr ratio the concomitant effects of structural and metabolic alteration can thereby be emphasized for diagnostic advantage. Conclusion: The Cho/Pcr-Cr is a very important and statistically significant marker (p = 0.043) determining the degree of intracranial astrocytoma malignancy.

An increasing body of evidence supports the concept that intracranial pressure (ICP) slow B waves represent the auto-regulatory response of spontaneous fluctuations of cerebral perfusion pressure. A relationship between cerebral auto-regulation and clinical outcome in patients with traumatic brain injury has also been established. The objective of our prospective clinical study was to compare the B slow ICP waves obtained invasively by standard ICP monitoring to those obtained noninvasively using a new ultrasound technology.In the participating institutions, over a period of six months, thirteen consecutive patients (8 males and 5 females) with severe closed head injuries (GCS8) were included in our IRB-approved study. Intracranial pressure and B slow waves, as well as arterial blood pressure and waveforms, were evaluated by standard invasive techniques. Additionally, a new non-invasive ultrasound device, Vittamed (Telematics Scientific Laboratory, Kaunas, Lithuania), was employed for monitoring intracranial blood volume slow waves. Using these modalities, it was possible to compare the changes that occurred with invasive monitoring (Correlation factor RI) and the changes that occurred using non-invasive technology (Correlation factor RN).Bland Altman plot analysis showed positive correlation between the invasively and non-invasively obtained slow intracranial B waves (2sigma = 8.9%, p0.0001) and cerebral auto-regulation indexes (RI and RN) (SD = 5%, p0.0001). Positive RI and RN values were correlated with poor clinical outcome.Ultrasonographic technology (Vittamed) may have significant application in non-invasive continuous cerebrovascular auto-regulation monitoring in patients with severe head injuries.

Two cases of epidural abscess as a complication of frontal sinusitis are presented. The diagnoses were suspected on the basis of history and were confirmed by magnetic resonance imaging and computed tomography. Both patients were treated successfully by means of surgery and intravenous antibiotics. One patient developed meningitis in the postoperative course and was treated by changing the antibiotic regimen. However, further follow-up in the outpatient clinic by physical examinations and brain computed tomography scans showed no longterm neurologic complications in either case. Intracranial suppuration, including epidural abscesses, can complicate acute and chronic frontal sinusitis. These complications are diagnosed by maintaining a high index of suspicion and using the appropriate neuroimaging studies without delay.

The objectives were to present a case of pediatric spinal oligodendroglioma and review the existing literature written in English on the subject of human spinal oligodendrogliomas. A comparison of the clinical, radiologic, and pathologic characteristics, as they relate to those already described in similar cases, was also attempted. Thorough evaluation of the patient’s clinical course was undertaken. Presenting symptoms and signs are reported. The perioperative radiologic features of the case are presented and the intraoperative details as well as the pathologoanatomic findings and follow-up history are provided. We subsequently performed a thorough search in the literature focusing on the number, characteristics, treatment modalities, and prognosis of patients with spinal cord oligodendrogliomas. Spinal oligodendrogliomas are a distinctly rare type of nervous system tumor, especially in the pediatric population. An international registry addressing all of their clinical and pathobiological characteristics would be of great benefit to patients harboring these rare tumors.

Intracranial temperature and its normal variation, as well as its response to various pathologic conditions, has become a critical component of monitoring in neurosurgical intensive care. In a prospective clinical study of 54 neurosurgical patients, intracranial pressure, cerebral perfusion pressure, and intraventricular and systemic temperatures were monitored in a neurosurgical intensive care unit. All of our patients' intraventricular temperatures were initially higher than their systemic temperatures. In 11 patients, the intraventricular temperature became lower than the systemic temperature, in a median time of 4.43 hours (range, 4.21-5.18 hours), prior to any changes in intracranial and cerebral perfusion pressures. Reversal of the disassociation between intraventricular and systemic temperatures may be an early marker of patients with a poor prognosis.

Study Design. Seventy patients undergoing de novolumbar microdiscectomy were prospectively randomized into a control group and a group in which cold intraoperative wound irrigation along with postoperative wound cooling was used. Postoperative analgesia requirements and length of hospital stay were analyzed and correlated. Objectives. To evaluate the role of intraoperative cold irrigation and postsurgical cooling in minimizing postoperative lumbar discectomy pain. Summary of Background Data. Regulated hypothermia has been used frequently in pain reduction; however, the efficacy of such a strategy in lumbar disc procedures has not been established. Methods. Seventy patients (43 men and 27 women), operated on the first time for lumbar disk herniation were prospectively randomized into two groups. A standard microdiscectomy was performed on all patients. In cohort A the wound site was irrigated with a cold (18 C) 5% bacitracin solution for 5 minutes. Additionally, a cooling microtemperature pump was placed on the wound site for 24 hours after surgery. The patients in the control group (cohort B) were treated in a standard fashion without additional hypothermic therapy. All patients received postoperative analgesia through a self-administered morphine pump. The amount of postoperative analgesia received was calculated in morphine equivalents per kilogram. The length of hospital stay was also noted. Results. The total amount of pain medication was significantly smaller in cohort A than in the control group (cohort B). For the statistical analysis of the results, covariate analyses for both the length of hospital stay and the morphine dose were used, demonstrating a statistically significant difference with P = 0.0001. No postoperative wound infection was noted in either group. Conclusions. Intraoperative and postoperative wound site cooling is a safe, inexpensive, and efficient therapeutic method. It reduces the patients’ postoperative pain, promotes earlier ambulation and decreases the length of hospital stay.

The authors studied whether the amount of retraction pressure applied to a compromised nerve root during lumbar discectomy has an impact on intra- or postoperative outcome. Methods The authors conducted a prospective analysis of 20 patients. There were 12 men and 12 women whose mean age (± standard deviation [SD]) was 42.25 years ± 15 years (range 21–65 years). During intraoperative electromyography (EMG) monitoring, measurements were obtained during routine retraction of the affected nerve root by using a specially designed and constructed nerve root retractor connected to a reconfigured personal computer for this specific purpose. Follow-up results were assessed in the immediate postoperative period and at up to 1 year. The maximum measured force applied during random periods of time was 9.85 N/second (mean 6.95 ± N/second [± SD]). The mean retraction time was 39.5 ± 21 (SD). No intraoperative EMG-detected irritation was noted during or after routine retraction. In four of 20 patients, sensory changes occurred at the ipsilateral nerve root level, which resolved at the time of discharge. Conclusions The authors found that routine nerve root retraction does not cause nerve root irritation, as demonstrated by EMG monitoring, nor was patient outcome affected in this series.

✓ The authors report a case in which acute renal failure developed following angiography and computerized tomography with infusion of contrast material performed within the same day.