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A cystic lesion adjacent to the dens with compression of the lower portion of the medulla oblongata was found on MRI in a 75-year-old male patient with a 2-month history of occipital pain and gait disturbance. Clinically, the patient showed mild tetraparesis, signs of spinal ataxia and symmetrical hyperreflexia. Following subtotal removal of the cyst via left-sided suboccipital craniotomy and left-sided hemilaminectomy of C1 the lesion was classified as synovial cyst on histopathological examination. Postoperatively, the quadriparesis almost completely subsided and the patient is currently doing well, 33 months after surgery. Synovial or ganglion cysts adjacent to the atlantoaxial articulation with ventral compression of the cervicomedullar cord represent rare surgical or radiological entities. Atlantoaxial synovial cysts have no typical radiographic appearance or specific neurological symptoms so that they are frequently misdiagnosed as intraspinal- or skull base tumour, rheumatoid lesion or ectatic vertebral artery. Since no ensuing complications or recurrences have been encountered in cases of incompletely removed cysts the less invasive operative approaches should be used to avoid destabilisation and subsequent additional surgical procedures.

Background: The prevailing percutaneous treatment options for herniated non-contained lumbar discs have not reliably achieved the same good results as the conventional microsurgical techniques. In this study we evaluated clinical outcome and complication rate following endoscopic percutaneous transforaminal treatment of extruded or sequestrated herniated lumbar discs in 122 patients with a follow-up period of more than one year. Method: Between October 1997 and December 2000, 86 male and 36 female patients with a median age of 55 years (range 18 to 89 years) underwent endoscopic treatment for non-contained herniated lumbar discs at our department. Neurological controls were conducted after 4 to 8 weeks routinely and the clinical result was reassessed at a follow-up of 15 to 53 months (median 35 months) according to the Macnab scale and Prolo outcome score. Findings: On follow-up examination, 96 patients were found with permanently ameliorated or normal clinical status following endoscopy alone. The remaining 26 cases with unchanged or only temporarily improved neurological disorders were submitted to conventional microsurgical interventions. Spinal nerve root injury during endoscopic treatment occurred in two patients but no additional neurological deficits or aggravation of pre-existing disorders were observed. Interpretation: Due to the minimal invasivity, the good functional outcome (78.7% clinical amelioration) and the low complication rate (1.6%), this procedure represents an attractive and efficient treatment alternative especially for foraminal and extraforaminal herniated lumbar discs and reduces the indications for open surgery in selected cases.

The purpose of the study was to determine the frequency of associated MR imaging findings in patients with symptomatic lumbar intraspinal synovial cysts, and to correlate MR with surgical findings. MR imaging studies of 18 patients with surgically and histopathologically proven lumbar intraspinal synovial cysts were retrospectively analyzed and correlated with surgical findings. The diameters of the synovial cysts ranged from 10 mm to 28 mm, with a mean of 16 mm. A nonhemorrhagic cyst was found in 15 patients (83%), and a hemorrhagic cyst in three patients (17%). Degenerative spondylolisthesis was found in six patients (33%) at the level of the synovial cyst, with displacement ranging from 3 to 5 mm, mean 4 mm. Surgery revealed instability and hypermobility of the facet joint at the level of the synovial cyst in all patients with degenerative spondylolisthesis, and in five additional patients. Symptomatic synovial cysts of the lumbar spine were associated with degenerative spondylolisthesis in six of 18 patients (33%) and with instability of the facet joint in 11 (61%). These findings may support the theory that increased segmental motion plays a role in the pathogenesis of synovial cysts.

OBJECTIVE—Synovial cysts of the vertebral facet joints are a source of nerve root compression. Different surgical procedures are in use, but no consensus has been formed so far as to which method should be used in synovial cysts. To clarify the role of surgical management, the efficacy of operative procedures and factors influencing the outcome in our own series of 19 patients treated between 1994and 1998 were analysed. METHODS—Nineteen patients with a mean age of 65 years underwent surgery for medically intractable radicular pain or neurological deficits caused by synovial cysts. The patients' records were retrospectively analysed for neurological deficits, cysts diameter, operative approach, segmental hypermobility, and clinical outcome; CT and MRI were analysed for additional degenerative changes. RESULTS—In 17 patients an excellent result and in two patients a good postoperative result was achieved. Twelve patients were found to have hypermobility of the facet joints and six had spondylolisthesis. There was no correlation between cyst diameter, operative approach, and outcome. No intraoperative or postoperative complications occurred. CONCLUSIONS—Age and hypermobility may play a part in the aetiology of facet joint synovial cysts. As all operative strategies showed equally good clinical outcome, total excision via a small flavectomy as the least invasive approach should be considered therapy of choice in patients with cysts causing neurological deficits.

Since its introduction into the clinical setting at the beginning of the 'eighties, transcranial Doppler sonography (TCD) has gained increasing acceptance as a non-invasive neuromonitoring technique. The ability of TCD to detect embolic particles within the cerebral blood vessels has been the subject of intensive investigation in recent years. In the present paper, a new method for the detection of emboli (multirange principle), intra-operatively during a neurosurgical intervention in a 35-year-old patient with a tumour in the posterior fossa and an open foramen ovale, is described for the first time. The method opens up new possibilities for the intra-operative management and the rapid assessment and diagnosis of paradoxical cerebral embolism.

Vascular injuries in lumbar disk surgery, although rare, are serious complications which may be overlooked due to a broad range of clinical manifestations. It is important that surgeons and radiologists be aware of these potentially fatal complications and develop an appropriate symptom-based diagnostic paradigm. We reviewed 8099 consecutive cases of lumbar disk surgery, performed over a 14-year period at a single institution, for postoperative vascular complications. We identified four patients (0.05%) with lumbar disk surgery-related vascular complications: intraoperative lacerations of the abdominal aorta and median sacral artery, an arteriovenous fistula between the left common iliac artery and vein detected 19 days postdiskectomy, and a partially thrombosed aortic aneurysm with an arteriovenous fistula between the aneurysm and the inferior vena cava, diagnosed 11 months after surgery. The majority of cases in the literature of vascular injury in lumbar disk surgery were reported prior to 1965. Diagnostic approaches described in that period do not reflect the great range of diagnostic techniques available today. Angiography remains the gold standard for diagnosis and guidance as to surgical repair. However, a high index of suspicion based on clinical signs and/or the use of sonography or CT is important in the detection of these complications.

Expansive granulomatous lesions in the posterior cranial fossa are rare and have not been reported in conjunction with Lyme disease. We report a patient with verified Borrelia burgdorferi infection who developed a tumor in the cerebellopontine angle. Rapid growth of the tumor led to signs of cerebral compression and to hydrocephalus. Surgical intervention was required despite florid meningitis. The histological examination showed inflammatory, nonspecific granulation tissue. The origin of this tissue is almost certainly causally related to the B. burgdorferi infection. Signs of inflammation resolved rapidly after subtotal resection. The clinical, radiological, and biochemical course is documented. This is the first report of an expansive cerebral lesion in the chronic phase of Lyme disease.

Aetiology and pathogenesis of eating disorders is a matter of controversy. In some cases they can occur in association with tumours involving the temporal cortex, in temporal lobe epilepsy or in the advanced state of degenerative diseases involving temporal structures. We report about three patients with right frontal intracerebral lesions, one oligo-astrocytoma and two vascular malformations, associated with partial seizures and anorexia nervosa. 3 patients, one female and two men with anorexia nervosa and right frontal intracerebral lesions were admitted to our wards due to focal seizures or loss of consciousness. They were treated either microsurgically or by endovascular embolization after neuro-imaging. In our retrospective analysis of the patients' reports and course we investigated the histopathology of the lesions, duration of the eating disorder and the clinical outcome. Two patients underwent craniotomy with extirpation of the lesion. In one case histology revealed an oligo-astrocytoma, in the other haemorrhagic infarction due to a venous malformation. The patient with the arteriovenous malformation (AVM) was embolized with microparticles. The patients with the oligoastrocytoma and AVM totally recovered. They gained weight and stayed seizure free. The patient with the infarction remained in a vegetative state. Right frontal intracerebral lesions with their close relationship to the limbic system could be causative for eating disorders. We therefore recommend performing a cranial MRI in all patients with suspected eating disorders, especially if they occur in combination with focal seizures.

BACKGROUND Meralgia paresthetica, a syndrome of pain and/or dysesthesia in the anterolateral thigh, is normally caused by an entrapment of the lateral femoral cutaneous nerve (LFCN) at the anterior superior iliac spine. In a few cases compression of the nerve in the retroperitoneum has been reported to mimic meralgia paresthetica. CASE DESCRIPTION A 67-year-old woman presented with a 5-year history of permanent paresthesia in the anterolateral thigh. Motor weakness was not detected. Electromyography showed a neurogenic lesion at the level of L3. Lumbar spine MRI detected a foraminal-extraforaminal disc herniation at L2/L3, which was extirpated via a lateral transmuscular approach. The patient was free of symptoms on the first postoperative day. CONCLUSION In patients with meralgia paresthetica we emphasize a complete radiological investigation of the lumbar spine, including MRI, to exclude radicular compression by a disc herniation or a tumour at the level of L2 or L3.

Since its introduction into the clinical setting at the beginning of the 'eighties, transcranial Doppler sonography (TCD) has gained increasing acceptance as a non-invasive neuromonitoring technique. The ability of TCD to detect embolic particles within the cerebral blood vessels has been the subject of intensive investigation in recent years. In the present paper, a new method for the detection of emboli (multirange principle), intra-operatively during a neurosurgical intervention in a 35-year-old patient with a tumour in the posterior fossa and an open foramen ovale, is described for the first time. The method opens up new possibilities for the intra-operative management and the rapid assessment and diagnosis of paradoxical cerebral embolism.

Over a period of seven years nine patients with vascular complications after lumber discectomy received medical care at the Clinic of Vascular Surgery, University of Graz Medical School. We report five acute bleeding complications occurring during the operation and four late manifestations of vascular lesions. Five patients presented with acute life-threatening iatrogenic haemorrhages from pelvic vessels. Three patients made a complete recovery, one patient died from acute haemorrhagic shock, one further patient died from sepsis due to an associated complication-an injury to the ureter. Over a period of two to ten years after primary surgery we corrected late complications such as 1 case of posttraumatic aneurysm of the aortic bifurcation found to have eroded the body of the fifth lumbar vertebra, and three cases of arteriovenous fistula between the common iliac artery and the common iliac vein. The four cases described below are an attempt to document the vascular surgical procedures involved and to provide typical findings. The risk of injuring the pelvic vessels intra-operatively can be explained by the close anatomical relation between the retroperitoneal vessels and the vertebral column and furthermore not only by the fact that pre-existent deficiencies but also injury to the anterior longitudinal ligament give access to the retroperitoneal space.

Of 107 patients (121 hands) operated for carpal tunnel syndrome at the University Clinic of Neurosurgery, Graz 99 patients were operated in local anesthesia. 82 patients (94 hands) came for follow-up examinations. After an average observation period of 19 months, the patients judged the postoperative results as follows (without regard to possible additional diseases): 78 hands (83%) "excellent" or "good", 13 hands (13.8%) "improved," and 3 "unchanged" (3.2%). On the basis of these results, the low stress for the patient, and the minimal rate of complications due to anesthesia, we recommend local anesthesia for surgical treatment of CTS.

In a review of the literature the current knowledge of the diagnostic significance of sialic acid (NANA), neuron-specific enolase (NSE) and carcinoembryonic antigen (CEA) in the detection and differentiation of brain tumors is demonstrated. The efficiency of some additional biochemical tumor markers is briefly described. In a total of 101 patients of our own 63 patients operated on intracranial expansive lesions and 38 patients with non-tumoral diseases of the central nervous system were examined for their serum concentrations of NANA, NSE and CEA with additional determination of total serum protein (TSP) and C-reactive protein (CRP) concentrations. 24 benign, 15 semibenign, 12 semimalign and 12 malign expansions were compared with each other and with the controls for their tumor marker concentrations. The criteria of the diagnostic reliability (sensitivity, specificity, positive and negative predictive value) were calculated for each single marker and the reliability of information for the combined used markers was evaluated. In summary the following results were found: The concentration of C-reactive protein corresponded significantly with the NANA-concentrations on the one hand and with the CEA-concentrations on the other hand (p less than 0.05). NANA: 1. The average concentration increased with increasing malignancy (no significance). 2. Patients who suffered from non-tumorous diseases of the central nervous system which coincided with brain tissue lesions had often extremely high values. 3. 4 of 10 healthy controls had NANA-levels above the reference value. 4. The sensitivity was 44%, the specificity 73%, the positive predictive value 17%, the negative predictive value 88% (patients with pathological CRP- or TSP-values excluded).(ABSTRACT TRUNCATED AT 250 WORDS)

One of the characteristics of malignant tumor cells is the production of glycocompounds with a high content of N-acetylneuraminic acid (sialic acid). Total sialic acid concentration was determined in the serum of 136 patients with an intracranial tumor. The concentration was determined enzymatically and using HPLC. Both methods had a relatively high specificity (90%), provided an inflammatory process due to an infection could be excluded. Sensitivity was 72.6%; the cut-off level of sialic acid concentration was determined to be 2.75 mumol/ml. There was a significant difference in the average sialic acid concentration of benign and malignant tumors. The test was least reliable in determining whether the growth of an astrocytoma is malignant.

210 patients harbouring an intracranial tumour were tested for CEA plasma levels. It could be shown that this investigation was neither a useful screening test for detecting brain neoplasms nor suitable for follow-up on operated brain tumours. However, with the CEA plasma investigation an additional preoperative test is available for distinguishing between primary and secondary brain tumours. The positive evidence is only 29%, but in case of a CEA plasma value above 5.0 ng/ml a metastasis is indicated with a probability of 91%.

Patients who had been operated on gliomas of the brain at the University clinic of Neurosurgery in Graz between 1950-1980 were questioned about their postoperative working capacity. 921 gliomatous brain tumors (Zülch's classification) out of a total number of 2430 intracranial space-occupying lesions are discussed. 79,7% of these patients had undergone an operation in which the tumor had been totally or partially resected. The histology of the tumor was compared to the operating mortality, survival time and postoperative working capacity.

A spontaneous acute spinal epidural haematoma during the course of an immune vasculitis is reported. Decompression by laminectomy after acute onset of paraplegia was followed by complete neurological recovery.