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A randomized trial showed that Surgery speeds up recovery of patients suffering sciatica for 6 weeks but Prolonged conservative care yields similar results at one year. However 39%,) of this conservative care group ultimately underwent surgery after a mean period of 18.7 weeks. We evaluated variables to improve prediction of surgery in the conservatively treated cohort. Baseline data on 142 patients enroled in the conservative treatment arm of a randomized trial were analyzed to select those that could contribute to the prediction of surgery. The actual occurrence of surgery was used as dependent outcome of interest. Variables measured at baseline included neurological examination results, the visual analogue scale for pain (VAS) and the Roland disability questionnaire (RDQ). Higher pain intensity and functional limitations at baseline were associated with an increased likelihood of surgery during follow-up. Mutually adjusted Odds Ratios of 1.7 (95% CI; 1.1-2.7) per 20 mm incremental intensification of pain on the VAS score and 1.8 (95% CI; 1.2-2.9) per 3 points of deterioration of the RDQ score quantify the increasing chance of undergoing delayed Surgery. Despite maximal efforts to the contrary, surgery Could not be prevented for a considerable proportion of patients in a conservatively treated cohort. Compared to those with lower scores initially, patients with more intense leg pain or higher disability scores were at higher risk to undergo delayed surgery. The individual surgical decision process is facilitated by the use of pain and disability scales complemented by patient preferences. (C) 2008 International Association For the Study of Pain. Published by Elsevier B.V. All rights reserved.

Sciatica caused by a lumbar disk herniation is a frequently diagnosed disorder with a favorable natural course. While most prognostic studies focus on good outcome, patients might experience unsatisfactory results. Female gender has been found to be associated with chronic pain in other musculoskeletal disorders. Our aim is to quantify the relationship between gender and (1) rate of recovery and (2) outcome at one year. Recovery was registered on a 7-point Likert scale for 283 patients with 6-12 weeks of persistent sciatica who participated in a randomized trial to investigate timing of surgery. Complete and near complete recovery were considered good outcomes. Function and pain were registered by the Roland Disability Questionnaire (RDQ) and a visual analogue scale (VAS). A univariate Cox model was used to study the influence of variables on rate of recovery while a univariate and multivariate logistic regression analysis evaluated variables predicting unsatisfactory outcome at 12 months. At one year unsatisfactory outcome was registered for 17% of patients, 11% of all males and 28% of all females (p < 0.001). Patients with an unsatisfactory outcome had worse RDQ and VAS scores compared to those who recovered satisfactorily (p < 0.001). Women had a slower rate of recovery: HR 0.76 (95% CI 0.59-0.99) and xbfnkbsdkvbated with an unsatisfactory outcome represented by an unadjusted odds ratio of 3.3 (95% CI 1.7-6.3) compared to males. Besides a slower recovery rate, female gender was a strong predictor of unsatisfactory outcome at one year for patients with sciatica. (c) 2007 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Background Rheumatoid arthritis is a chronic inflammatory disease, which affects 1% of the population. Hands and feet are most commonly involved followed by the cervical spine. The spinal column consists of vertebrae stabilized by an intricate network of ligaments. Especially in the upper cervical spine, rheumatoid arthritis can cause degeneration of these ligaments, causing laxity, instability and subluxation of the vertebral bodies. Subsequent compression of the spinal cord and medulla oblongata can cause severe neurological deficits and even sudden death. Once neurological deficits occur, progression is inevitable although the rapidity of progression is highly variable. The first signs and symptoms are pain at the back of the head caused by compression of the major occipital nerve, followed by loss of strength of arms and legs. The severity of the subluxation can be observed with radiological investigations (MRI, CT) with a high sensitivity. The authors have sent a Delphi Questionnaire about the current treatment strategies of craniocervical involvement by rheumatoid arthritis to an international forum of expert rheumatologists and surgeons. The timing of surgery in patients with radiographic instability without evidence of neurological deficit is an area of considerable controversy. If signs and symptoms of myelopathy are present there is little chance of recovery to normal levels after surgery. Design In this international multicenter randomized clinical trial, early surgical atlantoaxial fixation in patients with rheumatoid arthritis and radiological abnormalities without neurological deficits will be compared with prolonged conservative treatment. The main research question is whether early surgery can prevent radiological and neurological progression. A cost-effectivity analysis will be performed. 250 patients are needed to answer the research question. Discussion Early surgery could prevent serious neurological deficits, but may have peri-operative morbidity and loss of rotation of the head and neck. The objective of this study is to identify the best timing of surgery for patients at risk for the development of neurological signs and symptoms.

Background Open discectomy is the standard surgical procedure in the treatment of patients with long-lasting sciatica caused by lumbar disc herniation. Minimally invasive approaches such as microendoscopic discectomy have gained attention in recent years. Reduced tissue trauma allows early ambulation, short hospital stay and quick resumption of daily activities. A comparative cost-effectiveness study has not been performed yet. We present the design of a randomised controlled trial on cost-effectiveness of microendoscopic discectomy versus conventional open discectomy in patients with lumbar disc herniation. Methods/Design Patients (age 18–70 years) presenting with sciatica due to lumbar disc herniation lasting more than 6–8 weeks are included. Patients with disc herniation larger than 1/3 of the spinal canal diameter, or disc herniation less than 1/3 of the spinal canal diameter with concomitant lateral recess stenosis or sequestration, are eliglible for participation. Randomisation into microendoscopic discectomy or conventional unilateral transflaval discectomy will take place in the operating room after induction of anesthesia. The length of skin incision is equal in both groups. The primary outcome measure is the functional assessment of the patient, measured by the Roland Disability Questionnaire for Sciatica, at 8 weeks and 1 year after surgery. We will also evaluate several other outcome parameters, including perceived recovery, leg and back pain, incidence of re-operations, complications, serum creatine kinase, quality of life, medical consumption, absenteeism and costs. The study is a randomised prospective multi-institutional trial, in which two surgical techniques are compared in a parallel group design. Patients and research nurses are kept blinded of the allocated treatment during the follow-up period of 2 years. Discussion Currently, open discectomy is the golden standard in the surgical treatment of lumbar disc herniation. Whether microendoscopic discectomy is more cost-effective than unilateral transflaval discectomy has to be determined by this trial.

Pulmonary manifestations of systemic diseases remain very interesting disease entities. However, they are usually not very well known by the treating physician. Therefore, in the present Monograph, the editors have tried to gather a compilation of interesting pulmonary manifestations of very different disease entities, such as collagen vascular diseases and vasculitis syndromes, but also pulmonary involvement in renal, hepatic, gastrointestinal, neuromuscular, endocrine and metabolic, cardiovascular, immunodeficiency, and alpha-1-antitrypsin deficiency diseases. There is also a chapter on non-infectious pulmonary manifestations after organ and bone marrow transplantation (not including heart–lung or lung transplantation) and on acute respiratory distress syndrome (ARDS). The editors very much hope that this European Respiratory Monograph will provide the reader with an interesting overview and update on the possible pulmonary involvement and specific treatment options in different systemic diseases.

Nerve root decompression with instrumented fusion is currently most commonly performed in the treatment of patients with spondylolytic spondylolisthesis. The relationship between successful fusion and clinical outcome remains controversial, thereby questioning the necessity of fusion. Nerve root decompression without fusion, i.e. Gill's procedure, might be a less invasive surgical alternative with comparable clinical outcome. The objective of this study is to compare the long-term results of Gills's procedure with data from literature on decompression with fusion, and, moreover, to determine if a future randomised trial is legitimate. We retrospectively reviewed the long-term results of Gill's procedure in patients with grade I or II spondylolytic spondylolisthesis. All patients suffered from leg pain with or without low back pain. No patient had low back pain alone. In 17 patients a bilateral and in 25 patients a unilateral Gill's procedures were performed. The patients were evaluated at three follow-up moments. On moment 1, 38 patients were clinically examined on their last out-patient control (mean follow-up 11 months). On moment 2, 34 patients were interviewed by telephone (mean follow-up 4.4 years). The final long-term follow-up moment 3 (mean follow-up 10.5 years) included a mailed patient-satisfaction questionnaire of 31 patients (response rate 74%). No surgical complication occurred. Ten of the 42 patients were reoperated because of persistent or recurrent radicular pain (mean time interval 2.9 years). Kaplan-Meier analysis showed a disease-free survival rate of 79% at 5 years and 72% at 10 years after the index operation. On the three follow-up moments, the improvement of leg pain was 92, 97 and 88%, respectively. The final long-term follow-up showed 71% good result in terms of patient satisfaction. The Gill's procedure is a less invasive surgical technique in the treatment of patients with leg pain due to low-grade spondylolytic spondylolisthesis. This technique can be considered as an alternative to instrumented fusion in selected cases. Preoperative instability, discectomy at the affected level and neuroforaminal nerve root compression seem to be negative influencing factors, increasing the risk for secondary instrumented surgery. The results of this study justify a randomised trial.

Object.The aim of this retrospective study was to evaluate the restoration of shoulder function by means of suprascapular nerve neurotization in adult patients with proximal C-5 and C-6 lesions due to a severe brachial plexus traction injury. The primary goal of brachial plexus reconstructive surgery was to restore biceps muscle function and, secondarily, to reanimate shoulder function.Methods.Suprascapular nerve neurotization was performed by grafting the C-5 nerve in 24 patients and by accessory or hypoglossal nerve transfer in 29 patients. Additional neurotization involving the axillary nerve was performed in 18 patients.Postoperative needle electromyography studies of the supraspinatus, infraspinatus, and deltoid muscles showed signs of reinnervation in most patients; however, active glenohumeral shoulder function recovery was poor. In nine (17%) of 53 patients supraspinatus muscle strength was Medical Research Council (MRC) Grade 3 or 4 and in four patients (8%) infraspinatus muscle power was MRC Grade 3 or 4. In 18 patients in whom deltoid muscle reinnervation was attempted, MRC Grade 3 or 4 function was demonstrated in two (11%). In the overall group, eight patients (15%) exhibited glenohumeral abduction with a mean of 44 ± 17° (standard deviation [SD]; median 45°) and four patients (8%) exhibited glenohumeral exorotation with a mean of 48 ± 24° (SD; median 53°). In only three patients (6%) were both functions regained.Conclusions.The reanimation of shoulder function in patients with proximal C-5 and C-6 brachial plexus traction injuries following suprascapular nerve neurotization is disappointingly low.

This study focuses on the capacity of motor axons to elongate from the spinal cord through an autologous nerve graft into a spinal nerve. Applying a ventral surgical approach, C7 ventral roots were avulsed from the cord in 12 cats. Autologous saphenous nerve grafts were implanted into the cord at the ventral root outlet site and coaptated to the spinal nerve. Outgrowth of axons was studied at survival times 7, 14, 30, 60 and 120 days, respectively. The results showed horseradish peroxidase positive motoneurons in the C7 ventral horn after retrograde labeling, as well as neurofilament and acetylcholinesterase positive axons in the entire trajectory from spinal cord to spinal nerve. Neurotization of the C7 spinal nerve started between 14 and 30 days after graft implantation. In addition electrophysiology provided evidence that outgrowing axons had re-established functional contact with the spinodeltoid muscle at 120 days after implantation.

It has been reported that temporary external lumbar CSF drainage (ELD) is a very accurate test for predicting the outcome after ventricular shunting in patients with normal pressure hydrocephalus (NPH). However, only a limited number of patients have been studied for assessing the predictive accuracy of ELD. Therefore, the value of ELD in predicting the outcome after a ventriculoperitoneal shunt in patients with presumed NPH was assessed.All patients with presumed NPH were invited to participate in this study. Clinical assessment, MRI, and neuropsychological evaluation were followed by a lumbar CSF tap test consisting of removing 40 ml CSF. When this test resulted in marked clinical improvement of gait impairment, mental disturbances, or both, the patient was shunted without further tests. In patients with either questionable or no improvement after the CSF tap test, ELD was carried out. The value of ELD for predicting the outcome after shunting was calculated by correlating the results of ELD with that of ventriculoperitoneal shunting.Between January 1994 and December 2000, 49 presumed NPH patients from three institutes were included. Forty three had idiopathic, and the remaining six had secondary NPH. Forty eight patients were shunted; 39 had an ELD of whom 38 completed the test. After 2 months 35 of the 48 (73%) shunted patients had improved. The predictive value of a positive ELD was 87% (95% confidence interval (95% CI) 62-98) and that of a negative ELD 36% (95% CI 17-59). In two patients serious test related complications (meningitis) occurred without residual deficit.The study suggests that although the predictive value of a positive ELD is high, that of a negative ELD is deceptively low because of the high rate of false negative results. The costs and invasiveness of the test and the possibility of serious test related complications further limits its usefulness in managing patients with presumed NPH.

Object. The authors review the first series of 10 cases in which injured intraspinal brachial plexus were surgically repaired. They describe the technique of spinal cord implantation or repair of ruptured nerve roots, as well as patient outcome. Methods. Spinal root repair/implantation was performed from 10 days to 9 months postinjury. There were nine male patients and one female patient. Postoperatively in most cases, regeneration of motor neurons from the spinal cord to denervated muscles could be demonstrated, The first signs of regeneration were noted approximately 9 to 12 months postoperatively. Useful function with muscle power of at least Medical Research Council Grade 3 occurred in three of 10 cases. Magnetic brain stimulation studies revealed a normal amplitude and latency from the cortex to reinnervated muscles on surgically treated and control sides. A certain degree of cocontraction between antagonistic muscles (for example, biceps-triceps) compromised function. With time there was a reduction of cocontractions, probably due to spinal cord plasticity. In these cases there was also, surprisingly, a return of sensory function, although the mechanism by which this occurred is uncertain. Sensory stimulation (thermal and mechanical) within the avulsed dermatomes was perceived abnormally and/or experienced at remote sites. There was some return of patients' sense of joint position. Conclusions, A short time lag between the accident and the surgery was recognized as a significant factor for a successful outcome. Reimplantation of avulsed nerve roots may be combined with other procedures such as nerve transfers in severe cases of brachial plexus injury.

Object. The goal of this study was to find which central nervous system (CNS) pathways are involved in volitional control over reinnervated biceps or pectoral muscles. Methods. Intercostal nerves (ICNs) were coapted to the musculocutaneous nerve (MCN) or the medial pectoral nerve (MPN) in 23 patients with root avulsions of the brachial plexus to restore biceps or pectoral muscle function. The facilitatory effects of respiration and voluntary contraction on cortical motor-evoked potentials of biceps or pectoral muscles were used to study CNS control over the reinnervated muscles. The time course of the facilitatory effect of respiration and voluntary contraction differed significantly. In the end stage of nerve regeneration, the facilitatory effect of voluntary contraction was significantly larger than that of respiration, indicating that the CNS control network over the muscle comes to resemble that of the recipient nerve (MCN or MPN) rather than that of the donor nerve (ICN). Conclusions. The strengthening of previously subthreshold synaptic connections in a CNS network connecting ICN to MCN or MPN neurons may underlie changing excitability.

Objective Restoration of volitional control over elbow flexion has been demonstrated in patients who have undergone intercostal-to-musculocutaneous nerve transfer. We investigated the cortical area involved in the control over elbow flexion after intercostal-to-musculocutaneous nerve transfer. Methods Maps of magnetically excitable cortical areas of the affected arms of five patients were compared with maps of their healthy arms and maps of both arms of four healthy control subjects. The intercostal cortical area was also studied, requiring needle electromyography mapping (n = 1). Results The cortical areas of affected arms were smaller and less excitable than those of healthy arms. The locations of these areas could not be distinguished from that of the normal cortical biceps area but seemed to differ from that of the intercostal cortical area. Conclusion The existence of a biceps-like cortical area related to the reinnervated muscle can be explained in two ways. Interneurons from the original biceps area might excite the cortical neurons controlling the intercostal muscles. Alternatively, corticospinal neurons of the original biceps area may project directly onto spinal intercostal motor neurons. Cerebral plasticity does occur in intercostal-to-musculocutaneous nerve transfers and may be crucial for their clinical success.

Study Design. The authors investigated the innervation of discographically confirmed degenerated and ''painful'' human intervertebral discs. Objective. To determine the type and distribution patterns of nerve fibers present in degenerated human intervertebral discs. Summary of Background Data. The innervation of intervertebral discs has previously been extensively described in fetal and adult animals as well as humans. However, little is yet known about the innervation of severely degenerated human lumbar discs. The question may be posed whether a disc that has been removed for low back pain possesses an increased innervation compared with normal discs. Methods. The presence of nerve fibers was investigated using acetylcholinesterase enzyme histochemistry, as well as neurofilament and substance P immunocytochemistry. From 10 degenerated and 2 control discs, the anterior segments were excised and their nerve distribution studied by examining sequential sections. Results. In all specimens, nerve fibers of different diameters were found in the anterior longitudinal ligament and in the outer region of the disc. In 8 of 10 degenerated discs, fibers were also found in the inner parts of the disc. Substance P-immunoreactive nerve fibers were sporadically observed in the anterior longitudinal ligament and the outer zone of the anulus fibrosus. Conclusions. Findings indicate a more extensive disc innervation in the severely degenerated human lumbar disc compared with normal discs. The nociceptive properties of at least some of these nerves are highly suggested by their substance P immunoreactivity, which provides further evidence for the existence of a morphologic substrate of discogenic pain.

A ventral surgical approach is described for the grafting of autologous saphenous nerves between the spinal cord and the avulsed C7 ventral root in the cat. To overcome serious blood loss from the epidural venous plexus, the cats were hyperventilated (end tidal P co 2 to about 23 mmHg) and controlled hypotension was induced (mean arterial pressure to about 60 mmHg). After selective avulsion of the ventral rootlets C7 the saphenous grafts were implanted into the spinal cord and coaptated to the avulsed spinal nerve. The combination of advanced anesthetic methods and microsurgical techniques appeared to be mandatory to achieve a low surgical mortality. Regenerated axons were retrogradely traced using retrograde horseradish peroxidase (HRP), and their functional recovery was evaluated by means of electrophysiological methods.

The appearance and localization of the protein subunits of neurofilaments in the ascending and descending fibre systems of the developing rat spinal cord white matter were studied. The monoclonal antibody NF-90 (specific for the phosphorylated NF-L, NF-M and NF-H subunits) was used as neurofilament marker in fresh cryostat and Bouin fixed paraffin sections. The results were compared with Nissl and Bodian stained sections. Within the white matter, phosphorylated neurofilament proteins were expressed with regional variations. At embryonal day 12 (E12), the first positive fibres were found in the lateral funiculus. During further development, the peripheral region of the lateral funiculus showed an intense neurofilament staining, due to the presence of a higher number of fibres. From postnatal day 12 (P12) on, an increased amount of neurofilaments was found in the region close to the periphery, probably due to the presence of large calibre fibres. The dorsolateral part of the lateral funiculus filled in with fibres after birth, which indicated the extended development of the rubrospinal tract. At E13, positive fibres were present in the ventral commissure and the ventral funiculus. At E14, an increased amount of neurofilaments was detected in the periphery of the ventral funiculus. At maturity, an intense staining in the subsurface region could be found, due to the presence of large calibre fibres of the fasciculus longitudinalis medialis. At E13, the first neurofilament positive fibres were present in the dorsal funiculus. At this day, a concentration of fibres was found in the dorsal part of the dorsal root bifurcation zone and three days later, more fibres were detected in the medial part of the dorsal funiculus. At E18, a higher number of fibres was present in the dorsal region of the fasciculus gracilis. The mature fasciculus cuneatus showed an intense neurofilament staining, which was mainly present in large calibre fibres. The ventral part of the dorsal funiculus filled in with neurofilament positive fibres after birth. This indicated the relative late arrival of the corticospinal tract.

✓ Spinal nerve root avulsions frequently occur in brachial plexus injuries caused by traction. Such lesions are considered to afflict the central nervous system (CNS) and are, therefore, believed to be beyond surgical repair. The present experimental study was initiated to challenge this hypothesis. The ventral rootlets of C-7 were avulsed from the spinal cord in 28 cats via an anterior approach and subsequently reimplanted into the cord at the site of origin. In nonoperated control cats and cats undergoing reimplantation, electrophysiological experiments were performed and horseradish peroxidase was administered to the spinal nerve on the reimplanted side after survival times ranging from 6 to 293 days. Spinal cord sections in all cats were stained for neurofilament, acetylcholinesterase (AChE), Nissl, and glial fibrillary acidic protein. Horseradish peroxidase—labeled ventral horn motoneurons were found as early as 14 days after reimplantation and their number increased with time. On Days 209 and 293, the number of labeled neurons equaled the number of labeled ventral horn neurons in the two control cats that did not undergo surgery. Starting on Day 6 after reimplantation, the appearance of the ventral horn and the white matter in the neurofilament, AChE, and Nissl-stained sections changed as a result of the CNS response to the injury. A return to their normal appearance could be observed in these stainings from Day 209 onward. Glial fibrillary acidic protein—positive astrocytic tissue was consistently found in the ventral horn and in the white matter reimplantation area. From Day 69 onward, electrophysiological stimulation of the spinal nerve C-7 on the reimplanted side elicited an electromyogram response in the spinodeltoid muscle. The latency and threshold intensity of the C-7 responses were initially increased but equalized to match the nonoperated controls between 98 and 122 days after reimplantation. The results of this study show that functional regeneration of ventral horn neurons after root avulsion and subsequent reimplantation in the cat is possible.

From 1985 onwards we have aimed at operating on good-risk patients, i.e., those graded I-III on the WFNS SAH Scale, within 3 days after the aneurysmal bleed. We report on a series of 100 consecutive operations for saccular aneurysm, covering a period of 5 1/2 years. Early operations (in the above sense) were done in 57 good-risk but otherwise unselected patients. After a one year follow-up, 47 of them (82%) were found to have made a good recovery (Glasgow Outcome Score I). The outcome of (mostly early) surgery in 15 selected poor-risk patients (WFNS SAH Scale IV and V) was much less favourable. Late surgery (4 or more days after SAH) was performed in 28 good-risk patients, most of whom had been admitted several days or weeks after the bleeding. Almost all of these patients had a good outcome. It is argued that the known management results of delayed surgery, which during the deliberately chosen interval exposes the patient to the risk of rebleeding and vasospasm, have by now been surpassed by those of early surgery. However excellent the surgical results of delayed operations may be, early operation should become the treatment of choice in good-risk patients.

Objective To describe the audiometric results after stapes surgery in a consecutive series of patients with stapes footplate ankylosis combined with another ossicular middle ear anomaly. Study Design A retrospective analysis of charts collected between 1986 and 2001. Setting A tertiary referral center. Patients A total of 25 patients (30 ears) underwent exploratory tympanotomies and ossicular reconstruction. Main Outcome Measure Audiometric results. Results Overall, a mean gain in air conduction of 18 dB (from 49 dB to 31 dB) and a mean postoperative air-bone gap (ABG) of 20 dB (mean preoperative ABG, 40 dB) were observed. The ABG closure was 20 dB or less in 70% of cases, which is in agreement with the few results reported in the literature. Moreover, the audiometric results remained stable. In the group of ears with a syndrome, the mean gain of air conduction was only 19 dB, which was comparable to that observed among nonsyndromic ears. Conclusions Surgery for congenital stapes footplate ankylosis with a concomitant ossicular chain anomaly can provide worthwhile hearing improvement. The ABG closure was 20 dB or less in 21 of 30 ears (70%). Most ears had some sensorineural impairment (10-20 dB), which influenced the final hearing level after surgery. Over recent decades, the technique of the malleostapedotomy procedure has been improved. Preoperative assessment is mandatory for syndromal diagnoses, which might be important for patient counseling and prognosis.

1. Eleven patients undergoing lumbar discectomy received cloxacillin by continuous i.v. infusion, starting before the operation. During the operation several blood samples and one CSF sample were taken. 2. Mean rate constants describing the passive transfer of drug from plasma to CSF (kp) and the largely active transfer in the opposite direction (kCSF) were estimated. 3. In some subjects the CSF albumin quotient, defined as the ratio between the albumin concentration in CSF and in plasma times 1000, was slightly elevated (up to 23) which caused a significant increase in the value of kp. 4. The estimate of mean kp for healthy individuals was 0.065 h-1, which corresponds to a half-life of 10 h. The estimate of mean kCSF was 2.10 h-1. This predicts a steady-state CSF drug concentration which is 3% of the unbound plasma drug concentration. 5. There was a significant lag between the time courses of plasma and CSF drug concentrations, presumably reflecting the time for drug to move from the choroid plexus to the lumbar sampling site. 6. Four other patients received cloxacillin for prophylactic or therapeutic reasons by continuous i.v. infusion. In three of those patients the albumin quotient was normal or slightly elevated and the steady-state CCSF/Cu ratio was similar to the predicted normal value. 7. These findings indicate that eradicating staphylococci from CSF in cases of meningitis with a low degree of inflammation may be difficult.

Hitherto, the development of spinal cord neurons has mainly been studied with classical histological staining techniques (His 1889; Ramon Y Cajal 1890; Retzius 1898) and with [3H]thymidine autoradiography (Sauer 1959; Sidman et al. 1959; Fujita 1964; Nornes and Das 1974; Altman and Bayer 1984). During the last two decades, different neuronal tracers were used to study the development of the ascending and descending fiber systems in the spinal cord. Until recently, the use of such tracers in mammals appeared to be restricted to the postnatal period because of difficulties in prenatal administration. The development of an intrauterine operation technique (De Beer et al. 1989) and a method for more accurate prenatal tracer application (see Lakke and Hinderink 1989) appear to offer new possibilities for investigating the embryonal development of fiber systems by means of neuronal tracers. So far, the results indicate the applicability of these techniques in developmental studies of the rat spinal cord fiber systems (Lakke and Hinderink 1989; Lakke and Marani 1991; Wessels et al. 1990). This particular tracing technique is used successfully in the present study.

After selective avulsion of the ventral root cervical 7 (C7) from the adult cat spinal cord, the intraspinal trajectories of the torn axons in the white matter were studied at different survival times. Two phases could be discerned: an early phase which showed changes that occurred up to 14 days after avulsion and a second phase from day 30 onwards. Two days postoperatively, considerably swollen, empty myelin sheaths occurred, which remained present up to 14 days after avulsion. A primary increase in the number of glial cells (microglia) was noted on days 2 and 4 after avulsion. Ultrastructurally, unmyelinated and myelinated terminal clubs were found 8 and 14 days after avulsion. These clubs were characterized as cones of growth, related to axonal regeneration. A second glial increase was present after 30 days. At that time, the entire moto-axonal pathway clearly showed a degeneration pattern. This finding was light microscopically confirmed by an increase of GFAP-positive astrocytes. During the first 30 days, a front of small calibre myelinated axons, starting at the transition zone of the grey and white matter traversed halfway through the moto-axonal pathway. However, on days 60 and 90 no further shift of the front had occurred.

In the previous chapter, some of the results obtained with the described immuno- and enzyme histochemical techniques shed a new light on our knowledge about the developing rat spinal cord. Several of them will be discussed more extensively in the present chapter. With regard to the developing matrix and mantle layer, the roles of SSEA-1 and AChE will especially be emphasized.

The origin and course of the nerval innervation of the levator scapulae and rhomboid muscles was studied in four human cadavers. Special attention was given to surgical anatomy. The levator scapulae muscle receives two small segmental nerves from C3 and C4, respectively. The rhomboid muscle receives two segmental nerves, one from C4 and the other from C5. Moreover, in a series of 137 patients with a traumatic brachial plexus lesion, the linkage between levator scapulae and rhomboid muscle function impairment and site of the brachial plexus lesion was studied. Paresis of one or both of these muscles was noted in 13 cases. It was concluded that the rhomboid muscle may function on a single C4 nerve supply without any loss of strength. Arguments are put forward to support the relevance of rhomboid muscle testing in the assessment of brachial plexus lesions.

Needle EMG and polygraphic recordings of respiration and biceps activity were obtained in 7 patients who had undergone intercostal to musculocutaneous nerve transfer because of severe traumatic injury to the brachial plexus. EMG activity during expiration and inspiration was assessed during quiet breathing, deep breathing, and during sustained inspiration and expiration, and compared to the clinical strength of the biceps muscle. Biceps activity was consistently found during both expiration and inspiration, and in either case separately related to the flexion force levels. Initially this relationship appeared equally strong for both phases. With time, control over flexion changes from a completely respiratory-driven control to a conscious volitional control; however, involuntary effects of respiration always remained present in polygraphic recordings. Theoretical explanations for the change in control are put forward.

The localization of CD15 (synonyms: stage-specific embryonic antigen-1 (SSEA-1), 3(alpha)-fucosyl-N-acetyl-lactosamine or FAL), which is implicated in neuronal differentiation, in the developing dorsal rat spinal cord was studied by immunocytochemistry. A embryonal day 9 (E9), SSEA-1 was detected in the neural ectoderm and, at E11, in cells near the ventricle of the matrix layer. This localization indicated that SSEA-1 is present in proliferating premigratory cells of the rat spinal cord. Between E12 and E16, cells of the alar plate expressed SSEA-1. Expression of the antigen was restricted to neuroblasts that will form the dorsal horn. SSEA-1, therefore, can be used at this stage as a marker for a subdivision of the matrix layer. At E14, the dorsal root entrance zone showed SSEA-1. This indicated that SSEA-1 is associated with ingrowing primary afferents. From E16 on, SSEA-1 was present in the dorsal raphe, which suggested a function for SSEA-1 in the guidance of developing fibres. After E17, the antigen was also found within the dorsal mantle layer. SSEA-1 was first present in Rexed's laminae II, IV and V. Later on in development the antigen was detected only in Rexed's laminae II (substantia gelatinosa). These distribution patterns indicated that SSEA-1 is present on migratory and/or postmigratory cells. In addition, SSEA-1 is associated with small-diameter dorsal root fibres, the C fibres and A(sigma) fibres, that terminate within the substantia gelatinosa. After birth, SSEA-1 was present throughout the dorsal horn, probably as a result of the myelination of the fibres.

The use of the Gigli saw to deal with the inner bony ridges encountered in a mid-frontobasal or pterional craniotomy is presented. Despite the fact that power-driven craniotomes have certain advantages, the authors favour the Gigli saw in this situation.

Background The design of a randomized multicenter trial is presented on the effectiveness of a prolonged conservative treatment strategy compared with surgery in patients with persisting intense sciatica (lumbosacral radicular syndrome). Methods/design Patients presenting themselves to their general practitioner with disabling sciatica lasting less than twelve weeks are referred to the neurology outpatient department of one of the participating hospitals. After confirmation of the diagnosis and surgical indication MRI scanning is performed. If a distinct disc herniation is discerned which in addition covers the clinically expected site the patient is eligible for randomization. Depending on the outcome of the randomization scheme the patient will either be submitted to prolonged conservative care or surgery. Surgery will be carried out according to the guidelines and between six and twelve weeks after onset of complaints. The experimental therapy consists of a prolonged conservative treatment under supervision of the general practitioner, which may be followed by surgical intervention in case of persisting or progressive disability. The main primary outcome measure is the disease specific disability of daily functioning. Other primary outcome measures are perceived recovery and intensity of legpain. Secondary outcome measures encompass severity of complaints, quality of life, medical consumption, absenteeism, costs and preference. The main research question will be answered at 12 months after randomization. The total follow-up period covers two years. Discussion Evidence is lacking concerning the optimal treatment of lumbar disc induced sciatica. This pragmatic randomized trial, focusses on the 'timing' of intervention, and will contribute to the decision of the general practictioner and neurologist, regarding referral of patients for surgery.

The neurological and radiological findings in a case of chondrodystrophic dwarfism are described. The progressive tetraparesis proved to be based on a high-level medullary compression resulting from basilar impression and upper cervical stenosis. Surgical decompression led to the disappearance of the tetraparetic phenomena. Various aspects of chondrodystrophic dwarfism and basilar impression are discussed in relation to the neurological symptomatology, and the question of whether, in general, more attention should be given to the cranio-cervical region, is raised.

After a review of the literature on the origin of epidermoid tumors, a case report is presented of an intraventricular localization of such a tumor. Two theories are discussed as an explanation for this rare site. This case report, in addition to some data from the literature, suggests that it is unacceptable to assume that epidermoids have a primary location within the lateral ventricle.

Open myelotomies were performed in rat fetuses in stages E15−E19 with a microsurgical technique. To prevent oligohydramnios, considered to be one of the main causes of death associated with fetal surgery, amniotic fluid loss was reduced as much as possible. With this technique a reduction of the mortality rate to 38% was reached in 75 consecutive fetuses.

Diplopia can result from displacement of structures within the orbit and from ocular nerve palsies of a retro-orbital origin. Every change in the orbital content can lead to diplopia, as well in cases of increase e.g. tumour growth, as of decrease, e.g. loss of orbital fat due to surgery.

Choroid plexus papillomas in the posterior fossa can present with different clinical signs and symptoms. The tumors in the patients we discuss in this article originated from different sites of the choroid plexus. One patient, who had a fourth ventricle papilloma, experienced unsteady gait and episodes of dizziness over many years. The tumor was cystic an calcified, and adherent to the brain-stem. The second patient had only signs of increased intracranial pressure. A soft tumor was located in the cerebellomedullary cistern. The third patient, with a papilloma in the cerebellopontine angle, complained of hearing loss. This tumor was firmly adherent to the dura mater and looked exactly like a meningioma. The appearance on computed tomography scan, the macroscopic aspect, and the vascular supply of a papilloma in the posterior fossa can vary considerably.

✓ A case of a malignant neurofibroma of the cauda equina is described. Its location seems to be rare. An extensive surgical resection including the adjacent neural tissue and the enveloping dural sac was carried out, followed by radiotherapy.

Although the human adult brain is considered to be 10 times less sensitive to cancer induction by radiation than the bone marrow (ICRP, 1969) a relationship between X-ray therapy and subsequent intracranial sarcoma (Martin et al, 1980; Shin et al, 1980; Gerlach & Janisch, 1979; Schratz & Araoz, 1972; Noetzli & Malamud, 1962) and meningioma (Gomori & Shaked, 1982; Spallone, 1982; Iacono et al, 1981) has often been suggested in the literature. Few reports concern the possible association of human glioma and previous radiotherapy. The following case report describes a boy with a malignant astrocytoma in the mid-line of the cerebellum 14 years after X-ray therapy for craniopharyngioma. In our hospital this is the first case of a suspected radiation-induced brain tumour in 66 patients treated for cranial lesions by radiotherapy between 1969 and 1979 who have survived more than 5 years.

This paper deals with a case of brain abscess due to Streptobacillus moniliformis (the cause of the streptobacillary type of rat-bite fever) and Actinobacterium meyerii. Brain abscesses due to these micro-organisms are rare. The possible causative mechanisms in this particular case and the diagnostic and therapeutic management of brain abscesses in general are discussed.