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OBJECTIVE: Little is known about patient satisfaction and disability after brachial plexus surgery. Would patients undergo the procedure again, if they knew the current result beforehand ? How do they rate their result and their disability? METHODS: Of 319 plexus patients who had undergone surgery between 1995 and 2005, 199 received a 65-item questionnaire. Measurement instruments included a new plexus-specific outcome questionnaire (Ulm Questionnaire) with categories of satisfaction, functionality, pain, comorbidities, and work; and the disability of the arm, shoulder, and hand questionnaire (DASH; scale, 0-100). RESULTS: Of 99 returned questionnaires, 70 were returned in a useful form for evaluation. The results of patients with C5-C6 lesions (21 of 70) are as follows: 90% (19 of 21) would undergo surgery again, 95% (20 of 21) were satisfied with the result, and 86% (18 of 21) subjectively improved. The mean DASH score was 41 (standard deviation [SD], 24). The results of patients with C5-C7 lesions (6 of 70) are as follows: 50% (3 of 6) were satisfied and would undergo surgery again, and 67% (4 of 6) improved. The mean DASH score was 46 (SD, 13). The results of patients with C5-T1 lesions (43 of 70) are as follows: 67% (29 of 43) would undergo surgery again, 81 % (35 of 42) were satisfied, and 74% (32 of 43) reported improvement. The mean DASH score was 58 (SD, 26). The overall mean DASH score was 52 (SD, 26). Pain since the injury was prevalent in 86% of patients (60 of 70), back pain in 53%, and depression/anxiety in 21 %. Fifty-two percent of those who worked before their injury (27 of 53 patients) remained unemployed or incapacitated for work. Forty-five percent of previous workers (24 of 53) returned to their former occupation. Occupational retraining was successful for 70% of patients (16 of 23). The mean duration until return to work was 9 months overall and 5 months for those who returned to their previous occupation. CONCLUSION: Eighty-seven percent of patients were satisfied with the results and 83% would undergo the procedure again. Despite a high satisfaction rate, patients remained considerably disabled, and half of the previous workers did not return to work. Occupational retraining is effective.

We report on three adult patients with primary glioblastomas showing prominent adipocytic (lipomatous) differentiation, hence referred to as “glioblastomas with adipocyte‐like tumor cell differentiation.” Histologically, the tumors demonstrated typical features of glioblastoma but additionally contained areas consisting of glial fibrillary acidic protein (GFAP)‐positive astrocytic tumor cells resembling adipocytes, that is, containing large intracellular lipid vacuoles. Comparative genomic hybridization (CGH) and focused molecular genetic analyses demonstrated gains of chromosomes 7, losses of chromosomes 9 and 10, as well as homozygous deletion of p14(ARF) in one of the tumors. The second tumor showed gains of chromosomes 3, 4, 8q and 12 as well as losses of chromosomes 10, 13, 15q, 19 and 22. In addition, this tumor carried homozygous deletions of CDKN2A and p14(ARF) as well as point mutations in the TP53 and PTEN genes. The third tumor also had a mutation in the PTEN gene. None of the tumors demonstrated EGFR, CDK4 or MDM2 amplification. Taken together, our results define a rare glioblastoma differentiation pattern and indicate that glioblastomas with adipocyte‐like tumor cell differentiation share common molecular genetic features with other primary glioblastomas.

In the hands of the inexperienced, endoscopic carpal tunnel release bears a substantial risk for neurovascular injury. For those thoroughly trained in this technique, it is a fast and elegant but also more expensive way to achieve carpal tunnel release. If performed uneventfully, it minimizes trauma and avoids a substantial palmar skin incision. The authors think that some basic considerations are useful to prevent complications. This article focuses on some points that are relevant to the safe use of this technique.

As long as humans have been medically treated, unfortunate cases of inadvertent injury to nerves afflicted by the therapist have occurred. Most microsurgically treated iatrogenic nerve injuries occur directly during an operation. Certain nerves are at a higher risk than others, and certain procedures and regions of the body are more prone to sustaining nerve injury. A high degree of insecurity regarding the proper measures to take can be observed among medical practitioners. A major limiting factor in successful treatment is delayed referral for evaluation and reconstructive surgery. This article on iatrogenic nerve injuries intends to focus on relevant aspects of management from a nerve surgeon's perspective.

The aim of this study is to analyse short- and long-term results after surgical treatment of foramen magnum meningiomas and to identify the possible advantages of the posterior suboccipital approach over lateral and anterior approaches. Between 1992 and 2006, 16 patients with foramen magnum meningiomas were operated on in our institution, and in all cases a posterior suboccipital approach was utilised with lateral extension of the bone opening according to the position of the tumour. In 14 patients, intraoperative monitoring of the lower cranial nerves was performed. Localisation of the tumours was ventral (3), ventrolateral (10), dorsal (1) and dorsolateral (2). Mean age of the patients was 61 years (ranging from 40 to 85 years). Preoperative and postoperative function was classified according to the McCormick scale. We found in eight patients a postoperative upgrading of at least one grade, in five patients an unchanged status and a deterioration in only two patients. Complete removal of the tumour was possible in 14 cases (Simpson 1-2). The follow-up period varied from 24 to 119 months (mean 43.5 months), during this time there were no recurrences. Removal of foramen magnum meningiomas can be performed safely today with the use of microsurgical techniques and intraoperative monitoring. In our experience, the posterior suboccipital approach is suitable for the majority of these tumours.

OBJECTIVE Facial nerve paresis and hearing loss are common complications after vestibular schwannoma surgery. Experiments with facial nerves of the rat and retrospectively analyzed clinical studies showed a beneficial effect of vasoactive treatment on the preservation of facial and cochlear nerve functions. This prospective and open-label randomized pilot study is the first study of a prophylactic vasoactive treatment in vestibular schwannoma surgery. METHODS Thirty patients were randomized before surgery. One group (n = 14) received a vasoactive prophylaxis consisting of nimodipine and hydroxyethylstarch which was started the day before surgery and was continued until the seventh postoperative day. The other group (n = 16) did not receive preoperative medication. Intraoperative monitoring, including acoustic evoked potentials and continuous facial electromyelograms, was applied to all patients. However, when electrophysiological signs of a deterioration of facial or cochlear nerve function were detected in the group of patients without medication, vasoactive treatment was started immediately. Cochlear and facial nerve function were documented preoperatively, during the first 7 days postoperatively, and again after long-term observation. RESULTS Despite the limited number of patients, our results were significant using the Fisher's exact test (small no. of patients) for a better outcome after vestibular schwannoma surgery for both hearing (P = 0.041) and facial nerve (P = 0.045) preservation in the group of patients who received a prophylactic vasoactive treatment. CONCLUSION Prophylactic vasoactive treatment consisting of nimodipine and hydroxyethylstarch shows significantly better results concerning preservation of the facial and cochlear nerve function in vestibular schwannoma surgery. The prophylactic use is also superior to intraoperative vasoactive treatment.

In unserer neurochirurgischen Abteilung wurden in den letzten 10 Jahren 22 Patienten mit einer Lasion des Ramus superficialis N. radialis operiert. Allesamt klagten uber einseitige elektrisierende Schmerzen und Parasthesien isoliert im Versorgungsgebiet des Ramus superficialis N. radialis. Die haufigste Ursache war eine Spaltung des ersten Strecksehnenfaches bei Tendovaginitis stenosans de Quervain. In 8 Fallen wurde eine reine Neurolyse bei Erhalt der Kontinuitat durchgefuhrt, in 4 Fallen wurde das Neurom reseziert und der Nerv rekonstruiert (End-zu-End-Naht oder Einsatz eines Vicrylinterponats) und in 10 Fallen wurde das Neurom reseziert und der proximale Nervenstumpf in die Tiefe verlagert. Bei der Auswertung der postoperativen Ergebnisse (19 Patienten konnten uber einen mittleren Beobachtungszeitraum von 51 Monaten verfolgt werden) fiel auf, dass Schmerzfreiheit lediglich in 5 Fallen erzielt werden konnte. Sieben Patienten gaben eine unveranderte Beschwerdesymptomatik an, und in einem Fall trat durch die Intervention sogar eine Zunahme der Schmerzsymptomatik auf. Zufrieden stellende Ergebnisse (in 75% Schmerzfreiheit bzw. -reduktion) waren nur in der Gruppe der Patienten festzustellen, deren Neurom des Ramus superficialis N. radialis reseziert und der Nervenstumpf verlagert wurde. Aus unserer Sicht empfehlen wir deshalb bei Vorliegen einer traumatischen Lasion des Ramus superficialis N. radialis Zuruckhaltung betreffs eines chirurgischen Vorgehens. Des Weiteren ist eine Rekonstruktion des Nerven aus unserer Sicht nicht erstrebenswert.

Objective. Functional information concerning the surrounding brain is mandatory for a good clinical outcome in brain tumour surgery. The value of fMRI to detect the motorcortex and Broca’s area is widely accepted today. If an appropriate paradigm is used, short-term memory areas can be visualized as well. Obviously this information must be integrated into cranial neuronavigation for an appropriate intra-operative use. We report our first experiences with the direct integration of short-term memory fMRI into cranial neuronavigation. Method. From January 2001 to March 2002 14 patients were operated on for intracranial tumours with short-term memory fMRI imaging, using the “two-back-paradigm”. Both pre- and postoperatively, the short-term memory of all patients was tested additionally by a standardized test battery including 16 different verbal and visuo-spatial items. Results. In all 14 patients the general level of working memory capacity was preserved after surgery. The visuo-spatial performance was kept unchanged or deteriorated slightly, the alertness slightly worsened as well, but we found an improvement in verbal test items. Conclusion. The two-back paradigm is able to visualize verbal memory tasks in fMRI. For visuo-spatial items, a new paradigm has to be designed. In contrast to deep seated brain lesions, focal cortical impairments do not lead to obvious and serious memory deficits. Therefore, the aim of gross total tumour removal has to be balanced against the aim of preservation of short-term memory fields. Nevertheless, the knowledge of the localization of cortical short-term memory fields may combine both aims during navigated brain tumour surgery, thus preserving the patient with a better quality of life.

Lasionen des N. accessorius sind meist Folge einer iatrogenen Nervenlasion, insbesondere nach Lymphknotenexstirpationen im hinteren Halsdreieck. In der neurochirurgischen Klinik der Universitat Ulm wurden zwischen 1994–2003 31 Patienten aufgrund iatrogener Verletzungen des XI. Hirnnerven operiert. Davon ging allein bei 22/31 Patienten eine Lymphknotenexstirpation voraus. Alle Patienten wiesen eine Parese/Atrophie des M. trapezius auf, die Schulterabduktion war deutlich eingeschrankt. Neunundzwanzig von 31 Patienten auserten Schmerzen im Hals-Schulter-Bereich. Die operative Revision erfolgte 0–19 Monate posttraumatisch durch Neurolyse, End-zu-End-Naht oder Transplantation. Nach einer Nachbeobachtungszeit von durchschnittlich 12,6 Monaten waren 23% Patienten postoperativ komplett beschwerdefrei, bei 61% konnte eine funktionell relevante Verbesserung erreicht werden und lediglich 16% konnten von diesem Eingriff nicht profitieren. Zu einer Verschlechterung kam es in keinem der Falle. Bezuglich der OP-Verfahren sind die klinischen Ergebnisse auch bei der Notwendigkeit einer Nervennaht oder Transplantats nicht schlechter als nach einer externen Neurolyse bei erhaltener Kontinuitat. Insgesamt lasst sich feststellen, dass die Prognose einer mikroneurochirurgischen Therapie nach iatrogenen Lasionen des N. accessorius gunstig ist. Das Intervall zwischen Trauma und Revisionseingriff sollte unter 6 Monaten liegen. Bis zu einem Zeitraum von 12 Monaten kann eine funktionelle Remission erreicht werden, nachfolgend ist das klinische Outcome enttauschend.

Der Zeitpunkt der operativen Behandlung bei den intramedullaren Tumoren wird kontrovers diskutiert. In dieser retrospektiven Studie wird versucht die Frage zu beantworten, ob Patienten mit intramedullaren Ependymomen und Astrozytomen ohne oder mit nur leichten neurologischen Ausfallen eine bessere funktionelle Prognose postoperativ haben, als Patienten mit schweren praoperativen neurologischen Defiziten. In einem Zeitraum von 8,5 Jahren (Januar 1992–August 2000) wurden unter 34 Patienten mit intramedullaren Lasionen 10 Ependymome WHO-Grad-II und 5 Astrozytome WHO-Grad-II operativ behandelt. Zwei Astrozytome und 1 Ependymom mussten wegen Rezidiven nachoperiert werden. Das pra- und postoperative klinische Bild wurde nach der McCormick-Klassifikation in Grad I–IV dokumentiert (Grad I: keine oder milde neurologischen Defizite, Grad IV: schwere neurologische Ausfalle mit Abhangigkeit von fremder Hilfe). Die Nachuntersuchungszeiten schwankten zwischen 4 und 76 Monaten (Durchschnitt: 27,9 Monate). Alle 7 Patienten in Grad I blieben nach der Operation stabil. Zwei von den 4 Patienten in Grad II verbesserten sich, und 2 verschlechterten sich um 1 bzw. 2 Grade. Zwei von den 3 Patienten in Grad III und IV blieben postoperativ unverandert, und 1 verschlechterte sich von Grad III auf IV. Patienten mit intramedullaren Ependymomen und Astrozytomen sollen rechtzeitig operiert werden, wenn sie noch keine oder nur leichte neurologische Ausfalle zeigen, um ein gutes funktionelles Outcome zu erzielen.

Study Design. Retrospective clinical study. Objectives. To determine characteristics, treatment methods, and outcome in an institutional series of patients with spinal hematoma not related to previous surgery. Methods. The charts of all patients with spinal hematoma treated in our institution between January 1993 and December 2002 were reviewed and analyzed with regard to location and extension of the hematoma, duration of symptoms, neurologic status, diagnostic measures, therapy, and outcome. Results. Fifteen patients were identified with spinal hematomas not caused by previous spine surgery. There were 11 women and 4 men. One hematoma was located subdurally and another intramedullary. All other hematomas were extradural, with 10 spontaneous bleedings. Eight hematomas were located in the cervical, two in the cervicothoracic, and three in the thoracic region. Two others were situated in the lumbar spine. Mean extension was 4.7 segments (range, 2–8 segments). Mean interval between onset of symptoms and surgery was 18 hours (range, 8–48 hours) for 12 patients; in 2 cases, diagnosis was made after 17 and 36 days, respectively, and then treated by surgery. One patient was treated without operation. Operative treatment was accomplished in all cases by hemilaminectomy and/or interlaminar fenestration and hematoma evacuation, in those cases with a larger extension of extradural hematoma by an alternating hemilaminectomy, thus reducing the risk of postoperative instability. There was no recurrence. No correlation between time to surgery and outcome was found in this study group, but there was a strong correlation between initial neurologic status and outcome after surgery. Conclusions. Nonsurgical derived spinal hematomas are rare. In this series, most cases were spontaneous and located in the cervical or cervicothoracic region producing severe neurologic deficit and pain. Treatment should be surgical evacuation in the majority. As most hematomas are of great extension, alternating hemilaminectomy suffices for evacuation of extradural hematomas and supports the stability of the spinal segments. Outcome is highly dependent from initial neurologic status.

We report on a 37-year-old woman with a 10-week history of neck pain and brachialgia along the right C6 dermatome. Neurological findings included weakness of the right biceps muscle and hypesthesia of the right thumb. The patient was diagnosed as having von Recklinghausen’s disease (neurofibromatosis 1) 10 years ago, and a CT scan demonstrated an extraspinal paravertebral mass with osseous arrosion of the right vertebral foramen at C6. The primary diagnosis was neurofibroma, but further diagnostic workup including MRI, MR angiography and digital subtraction angiography revealed an extracranial vertebral artery aneurysm compressing the right C6 root. An attempt to occlude the aneurysm by coil embolization failed in another institution. Further interventions were rejected by the patient who experienced spontaneous resolution of her complaints and complete neurological recovery within a few weeks.

The unstable atlas burst fracture ("Jefferson fracture") is a fracture of the anterior and posterior atlantal arch with rupture of the transverse atlantal ligament and an incongruence of the atlanto-occipital and the atlanto-axial joint facets. The question whether it has to be treated surgically or nonsurgically is still discussed and remains controversial. During the last decade 8 patients with unstable atlas burst fractures were examined and treated in our department. Five of the eight patients were first treated conservatively by external immobilization. Because of continuing instability due to insufficient bony fusion of the atlantal fracture all five patients underwent atlanto-axial transarticular screw fixation and fusion - as described by Magerl - with good results. In all 8 patients a good bony fusion of the atlanto-axial segment was achieved. None of the patients exhibited neurological deficits after surgical treatment. Although immobilization with a halo vest is recommended by most authors, from our view primary transarticular C1-C2 screw fixation has to be discussed as an alternative for unstable atlas burst fractures. Nonsurgical treatment with halo extension always bears the risk of insufficient healing with further instability and a fixated incongruence of the atlanto-occipital and the atlanto-axial joints, leading to arthrosis, immobility and increasing neck pain. After 10 weeks of insufficient immobilization secondary pre- and intra-operative reposition manoeuvres and surgical fixation hardly can reverse this fixated incongruence. Moreover, halo-extension needs an immobilization of the cervical spine for about 10 weeks and more, which is very uncomfortable and leads to further complications especially in elderly patients.

Cavernous malformations are vascular anomalies that can cause severe neurological deficits, seizures and hemorrhagic stroke if these lesions are located in the brain. In patients with cavernomas, constitutional mutations of the KRIT1 gene have been identified. The pathogenetic mechanisms leading to cerebral cavernous malformations (CCM) development are poorly understood. CCM development might be induced in utero owing to the underlying KRIT1 defect, and is triggered by environmental factors. Another model suggests that CCM develop according to the two-hit model of tumorigenesis associated with biallelic inactivation of KRIT1. So far, CCM specimens themselves have not been subjected to mutation analysis. We identified two somatic mutations in the cavernoma of a sporadic case, suggesting that pathogenesis is associated with somatic KRIT1 alterations. To gain a better understanding of the role of KRIT1 during morphogenesis, the main goal of this study was to provide a detailed description of the spatio-temporal expression pattern of Krit1 and its interaction partner Rap1A during mouse embryogenesis. We did not observe enhanced expression of either gene in the heart or large vessels; however, their expression in the developing small vessels or capillaries could not be assessed by the methods applied. At early embryonic stages, Krit1 and, to a lesser extent, Rap1A are expressed in the developing nervous system. During later phases of fetal development, specific expression of both genes is observed in regions of ossification, the dermis, tendons and in the meninges. These findings provide evidence of differential Krit1 and Rap1A expression during mouse ontogenesis and suggest a more widespread functional significance of Krit1, not restricted to vascular endothelial cells.

Whereas cranial neuronavigation is widely accepted as a helpful tool, larger series of the in vivo application of spinal neuronavigation do not exist. In the following we report our 4-year experience with spinal navigation in 75 consecutive cases for dorsal transpedicular screw placement. Seventy-five patients were planned for operation employing anatomical reference points defined on a 2-mm high resolution CT. We used single vertebra registration and surface matching. With the above methods, the mean registration deviation ranged from 0.18 mm (cervical spine) to 0.31 mm (lumbar spine). All our screws in the upper cervical spine were navigated correctly (17 patients), thus improving markedly the surgical outcome. The results were not as promising in the lumbar area. In only 84% was navigation reliable. The reason was the lack of a practicable tracking tool. Spinal neuronavigation based on anatomical reference points is able to improve the results in transpedicular screwing, especially in the cervical spine. The lack of a practicable tracking tool still hinders its use in routine clinical application.

OBJECTIVE This is the first report of the direct integration of functional magnetic resonance imaging (fMRI) and positron emission tomography (PET) data into cranial neuronavigation. METHODS In a patient with a left precentral oligodendroglioma (World Health Organization Grade III), the Zeiss MKM system (Carl Zeiss Co., Oberkochen, Germany) was used for navigation based on thin-slice, T1-weighted, contrast-enhanced magnetic resonance imaging (MRI) scans. fMRI and methionine PET data were integrated by landmark matching, with reference to skin fiducials. RESULTS The inaccuracy of the image fusion between fMRI and T1-weighted MRI data was 1.7 mm, that between PET and T1-weighted MRI data was 4.3 mm, and that for the subsequent registration of the navigation was 1.2 mm. The correct fMRI localization of the precentral gyrus was intraoperatively verified by cortical somatosensory evoked potential (phase-reversal) monitoring. Although the tumor was not clearly defined in the MRI scans, [11C]methionine PET demonstrated a clear tumor border, enabling us to achieve gross total tumor removal without postoperative functional deficits. CONCLUSION Functional neuronavigation permits observation and preservation of relevant brain areas. Other functional areas (such as short-term memory areas) that can be detected only by fMRI might also warrant future monitoring. The simultaneous integration of fMRI and PET data adds a new dimension to cranial neuronavigation, enabling the observation of tumors in relation to functional cortical areas (in our case, the motor strip).

Four patients with primary intracranial high-grade gliomas are reported. Three of them developed spinal symptoms and signs generated by spinal metastases a few months after first diagnosis, the last patient developed an extraspinal metastasis in cervical lymph nodes. The spinal metastasis of a 30 years old patient was located intradurally at L5/S1, in the second patient at level L3, the third patient presented with multiple metastases in the cervical, thoracic and lumbar spine. Previously reported cases are reviewed, are discussed in the light of our own observations and analysed for the various therapeutic options.

Nach exzessivem Squash-Spielen entwickelte ein 27jahriger, sonst gesunder Mann eine isolierte, vollstandige Axillarisparese. Als sich nach 3 Monaten weder klinisch noch elektrophysiologisch Zeichen der Erholung der Nervenfunktion fanden, wurde der Nerv operativ freigelegt. Dabei zeigte sich nach der Epineurotomie eine sanduhrformige Ausdunnung des N. axillaris kurz nach dessen Abgang aus dem Fasciculus posterior. Da auch die intraoperative, elektrophysiologische Testung negativ war (kein Nervenaktionspotential uber die Verletzungsstelle ableitbar), wurde das auffallige Nervensegment reseziert und die Nervenkontinuitat mittels autologer Suralisinterponate wiederhergestellt. Die histologische Aufarbeitung ergab den vollstandigen Verlust nervaler Strukturen im Bereich der Ausdunnung. Als Ursache dieser Nervenlasion kommt am ehesten eine Uberdehnung in Frage. Postoperative Verlaufsuntersuchungen zeigten eine zunehmende Reinnervation.

Fourteen patients with traumatic brachial plexus injuries underwent intradural inspection of cervical nerve roots to evaluate radiological and intra-operative electrophysiological findings concerning cervical nerve root avulsion from the spinal cord. Four neurosurgeons of our department assessed independently from each other both myelography and CT-myelography concerning intradural nerve root lesions. Each neurosurgeon assessed a total of 26 cervical nerve roots. Two investigators assessed 6/26 and 2 investigators 7/26 nerve roots falsely concerning ventral or/and dorsal root lesions compared with the findings on intradural inspection (23% and 27% false findings). There was a considerable variance concerning the assessibility and findings among the 4 neurosurgeons. Reconstructive surgery was performed after a mean interval of 6.5 months following trauma and 2 weeks following intradural inspection. After exposure of the brachial plexus and the cervical nerve roots in question via a ventral approach, 13 cervical nerve roots were stimulated electrically close to the neuroforamen and cortical evoked potentials (root-SEPs) were recorded from the contralateral postcentral region. All 5 roots with SEPs were intact (no root lesion) and all 8 roots without SEPs showed interrupted (ventral or/and dorsal) rootlets on intradural inspection. Our results demonstrate that false radiological findings concerning root lesions are possible. Intra-operative root-SEPs seem to be a useful aid for evaluation of cervical nerve root lesions. However, more electrophysiological data are necessary to ascertain, if this modality is able to replace intradural inspection in unclear radiological cases in the future.

Die lumbale Spinalkanalstenose gilt heute als eigenstandiges Krankheitsbild. Man unterscheidet klinisch und radiologisch 2 Formen, die zentrale und die laterale Spinalstenose. Die Foramenstenose ist eine Sonderform der lateralen Stenose. Bei 109 von 148 Patienten, die wegen einer Spinalstenose in den Jahren 1990 und 1991 operiert wurden, wurde 3 Jahre nach der Operation anhand eines standardisierten Fragebogens der aktuelle Zustand bezuglich Schmerzen und Gehfahigkeit erfast. Patienten mit nachgewiesener Spondylolisthese oder degenerativer Instabilitat waren ausgeschlossen. 11/109 Patienten machten keine Angaben. 44/109 waren schmerzfrei, 35/109 deutlich gebessert. Bei 19 Patienten waren die Schmerzen nach der Operation nicht besser oder hatten sogar zugenommen. 74/109 Patienten waren postoperativ uneingeschrankt, 14/109 eingeschrankt und 6 weitere nur mit Gehhilfe gehfahig. 7/109 Patienten waren aufgrund anderer Leiden nicht gehfahig und 8 Patienten wurden wegen fehlender Angaben nicht berucksichtigt.

Objective: To determine the neurological outcome in patients with laminar fractures associated with dural tears and nerve root entrapment, operated upon for thoracic and lumbar spine injuries. Patient population: Out of 103 patients operated upon consecutively for thoracic and lumbar spine injuries during the period 1990 to 1994 inclusive, 24 (23.3%) patients had laminar fractures out of whom 3 (2.9%) had an associated dural tear and an other 17 (16.5% or 70.8% of the total patients with laminar fractures) had an associated dural tear and nerve root entrapment. Results: Twelve (70.5%) patients had injury at the thoraculumbar junction, 13 (76.5%) had Magerl's type A3 or above, 10 (58.8) had a kyphotic angle deformity greater than 5°. Seven (41.1%) had their spinal canal's sagittal diameter reduced by at least 50% and two had dislocations. Nine (52.9%) had initial neurological deficits. Four (50%) out of 8 patients with no initial neurological deficits (Frankel E) worsened to Frankel D. However, one patient among the 3 with initial Frankel A improved to Frankel C while both patients with initial Frankel C usefully improved to final Frankel grades D and E respectively. Two of the four patients with initial Frankel D improved to Frankel E, the other 2 remaining unchanged. All in all five patients' neurological status improved, 4 worsened and 8 remained unchanged after neurosurgical treatment. Conclusions: Vertical laminar fractures with dural tears and nerve root entrapment represent a special group of thoracic and lumbar spine injuries that carry a poor prognosis. However, special operative precautions lead to significant improvement in some of them although a majority remain unchanged or even worsened.

OBJECTIVE: Fifty-eight percent of patients who had undergone surgery for ulnar neuropathy at the elbow experienced pain after surgery. Severe pain, mostly radiating from the elbow into the hand, is the main indication for subsequent surgery. METHODS: During a period of 5.5 years, 25 patients underwent 28 operations for ulnar nerve entrapment at the elbow and experienced excruciating pain after surgery. Ten patients had undergone a simple decompression and 15 had undergone a nerve transposition. Seven patients underwent surgery at our hospital, whereas 18 patients underwent their primary surgery at other institutions. Various surgical techniques were used during the subsequent surgery, such as external or internal neurolysis, epineurectomy, anterior transposition, and subsequent transfer of the nerve back into the sulcus. RESULTS: The average follow-up after the last procedure was 17 months (2-55 mo). All five patients with subsequent transfer of the ulnar nerve into the sulcus became pain-free, whereas only two of five patients who had secondary intramuscular transposition for subluxation became free of pain. Results after internal neurolysis were unsatisfactory. Only one of six patients was free of pain after secondary surgery. Results after three or four procedures are approximately similar to the results after the first subsequent surgery. CONCLUSION: Simple and less extensive techniques for subsequent surgery have relatively good results in this complicated condition. Although our small number of patients does not allow us to draw general conclusions, we think our report makes a contribution because of the few reports in the literature dealing with the results of subsequent surgery for ulnar nerve neuropathy.

Intraspinale Ganglien- und Synovialzysten (Juxtafacettenzysten) mit Nervenwurzelkompression sind extrem selten. Ihr Nachweis gelingt am besten mit der Kernspintomographie. Die Behandlungsmethode der Wahl ist die operative Resektion der Zyste. Es gibt aber auch spontane Remissionen dieser Zysten. Durch eine CT-gestutzte Kortikosteroidinjektion werden die Symptome in der Regel nur passager behoben. In einer retrospektiven Studie uber einen Zeitraum von 16,5 Jahren fanden wir unter 19107 operierten lumbalen und thorakalen Wurzelkompressionssyndromen 24 Juxtafacettenzysten (10 Ganglien- und 14 Synovialzysten). 16 waren im Segment L4/5, 3 im Segment L5/S1, 2 im Segment L3/4 und je 1 in den Segmenten L2/3, L1/2 und Th10/11 lokalisiert. 7 Patienten hatten nur radikulare Schmerzen, die restlichen 17 zusatzlich neurologische Storungen. Bei 14 Patienten wurde nur die Zyste entfernt, bei 10 Patienten zusatzlich die Bandscheibe ausgeraumt. 23/24 Patienten konnten zwischen 6 Monaten und 10 Jahren (Durchschnitt 26,6 Monate) untersucht werden. 74% der Patienten waren radikular schmerzfrei. In 89% der Falle bildeten sich die motorischen und in 73% die sensiblen Storungen vollstandig zuruck.

OBJECTIVE : To evaluate the indication of subsequent operations after failed microvascular decompression (MVD) for the treatment of trigeminal neuralgia, the intraoperative findings and long-term results of 16 subsequent operations are reported. METHODS : Subsequent exploration of the posterior fossa was performed for lack of pain relief (3 patients) and recurrent neuralgia (13 patients) after an average of 17 months (range, 4-62 mo). In all patients, typical arterial compression patterns at the root entry zone of the trigeminal nerve were found in the first procedure. The mean follow-up period after subsequent operation was 90 months (range, 78-104 mo). RESULTS : New arterial neurovascular conflicts were found in nine patients. After subsequent MVD procedures, seven patients were pain-free (with one recurrence after 6 mo), one had constant marked relief, and one was unchanged. Second exploration revealed no abnormalities in the other seven patients who experienced continued or recurrent pain ; only careful neurolysis of the trigeminal nerve was performed in those patients. Initially, all seven patients obtained complete pain relief, but two experienced late recurrences after 64 and 68 months, respectively. Thus, subsequent operations failed in all 4 patients who had undergone prior destructive procedures but were successful in those 12 patients who had undergone only previous MVD. Two patients developed severe sequelae, and the other nine had minor complications, especially permanent (four patients) or transitory (three patients) ipsilateral trigeminal hypoesthesia. CONCLUSION : Subsequent MVD seems to have good long-term results. However, because of the significantly high incidence of complications, the indication for subsequent operations should be restricted to younger patients to avoid destructive procedures. In general, glycerol rhizolysis or radiofrequency rhizotomy may be the treatment of choice after failed MVD.

We report 43 consecutive surgically treated patients with pyogenic (37 patients) and tuberculous (6 patients) osteomyelitis of the thoracic and lumbar spine encountered within an 8-year period, including 1 with late recurrence after 15 months. There were 24 men and 18 women, ranging in age from 21 to 83 years. Twenty-six patients were in poor general condition because of associated illnesses, especially diabetes mellitus. Disease occurred at the thoracic level in 19 patients and on the lumbar spine in 24. After diagnosis, five patients were merely treated by posterior decompression; three of them, however, required further surgery for recurrent infection, spinal instability, and secondary neurological impairment. They are included in the 40 patients who underwent combined posterior débridement and internal fixation with transpedicular screw-rod systems. Autologous interbody bone grafting was performed simultaneously in 18 patients and in a second stage operation in 21 patients. One of them (tuberculous) experienced early recurrence and required anterior fusion. In two patients, methylmethacrylate packing was used for spine reconstruction; one of them had a late recurrence. Of the 26 patients with preoperative marked or severe neurological deficit (Frankel Grades A, 2 patients; B, 1 patient; C, 17 patients; and D, 6 patients), 23 (88%) had significant improvement of one grade (15 patients) or more (8 patients). There were no permanent complications. However, intensive care treatment was necessary in 20 of the 26 patients in reduced general condition (mean age, 72 yr). Two patients required further surgery because of postoperative epidural hematoma and pedicle screw malpositioning. In conclusion, most patients with thoracic and lumbar osteomyelitis can be successfully treated by combined débridement and internal fixation using only a posterior approach. Autogenous interbody bone grafting can be simultaneously performed and allows early mobilization of the patient.

The results of 58 dorsal root entry zone (DREZ) thermocoagulation procedures in 51 patients are reported. The postoperative analgesic effect was judged by the patients as being good (more than 75% pain reduction), fair (25–75% pain reduction) or poor (less than 25% pain reduction). Of the 14 patients who underwent surgery for pain due to cervical root avulsion, 10 (77%) had permanently good (8) or fair (2) pain relief after a mean follow up period of 76 months, another 2 (15%) experienced recurrence to the pre-operative level (initially 1 good, 1 fair) after more than 2 and 4 years, respectively. Twenty two paraplegics were operated upon, 3 of whom twice, for intractable pain. After a mean observation time of 54 months, continuing pain relief was reported by 12 (55%) patients (11 good, 1 fair), and one (initially fair) had recurrent pain after 8 months. All 3 (early) re-operations remain successful for an average period of 75 months. Poor results were seen especially in cases of associated spinal cord cysts (5 out of 7), despite combined drainage, and in patients with diffuse pain distribution (5 out of 6). Continuous marked improvement for longer periods (mean follow up: 52 months) after DREZ lesions was reported only by 2 out of 10 patients with postherpetic neuralgia (12 procedures) and by 1 out of 5 with painful states due to radiation-induced brachial plexopathy (2), previous surgery (2) and malignant tumour infiltration of the brachial plexus (1). Three patients died postoperatively due to acute cardiac failure (2) and pulmonary embolism (1). Major complications, especially permanent gait disturbances were observed in 6 patients (12%) following primary procedures and in 2 out of 7 patients after re-operations, most of them suffering from postherpetic neuralgia. Minor neurological deficits were noted in 9 cases (18%). DREZ lesions revealed to be an effective procedure in patients with pain related to root avulsion and paraplegia. In contrast, it seems to be less successful for painful states due to other plexus lesions or postherpetic neuralgia.

The results of selective peripheral denervation in 50 patients with spasmodic torticollis are presented. Of our patients, 76% reported a significant improvement or disappearance of their dystonia. The mean follow-up is 25 months. There were no major side effects. We recommend the procedure to patients who primarily have responded to botulinum toxin therapy and had become secondary nonresponders or to those refusing further injections while still responding. The results are much less promising in patients who are primary nonresponders to botulinum toxin. Some remarkable histological findings are presented. The posterior branches of the cervical roots frequently showed signs of severe compression neuropathy. In three cases, a functional motor nerve regeneration was proved. Among all surgical options, selective peripheral denervation provides the best result and has the fewest side effects.

STUDY DESIGN Prospective controlled clinical study. OBJECTIVE The aim of this prospective nonrandomized study is to evaluate the recurrence rate and the clinical outcome of patients undergoing sole sequestrectomy and compare them with a standard treatment group. SUMMARY OF BACKGROUND DATA While performing microsurgical disc excision, extruded disc fragments and loosened or degenerated parts of the nucleus are removed. It is controversial whether this strategy is always necessary. Within the literature, there is only little information about the results of exclusive sequestrectomy. METHODS Criteria for performing a sole sequestrectomy were a nonbulging disc and only small or medium perforations within the fibrous ring. According to these criteria, the authors recruited 90 patients for the sequestrectomy group. The control group was operated in standard microsurgical manner during the same time, including 84 patients. A detailed analysis of the actual pain status, the functional capacity (Hannover Activities of Daily Living Questionnaire, FFbH) and eventually additional spinal operations during the follow-up of 2 years was performed. RESULTS Mean Funktionsfragebogen Hannover (FFbH) score at the follow-up was 76% in the sequestrectomy group and 77.6% in the control group. This difference is statistically not significant. There were 2 recurrences in the sequestrectomy group at the same level and 1 postoperative instability requiring a fusion procedure. In the control group, there were 2 recurrences and 1 secondary lateral spinal stenosis that led to reoperations. The competence of the fibrous ring influenced significantly the success of a simple sequestrectomy. CONCLUSION The sole sequestrectomy group revealed similar results compared with the standard microdiscectomy group. There is a comparable low number of recurrences in both groups. This is probably caused by the consequent selection of patients for sequestrectomy according to well-defined criteria.

Objective In this study, we compare different surgical procedures regarding the functional outcome of traumatic peroneal nerve lesions. Methods In a retrospective study, 48 patients with traumatic lesions (17 iatrogenic) of the peroneal nerve were evaluated. Twenty-two patients presented with lesions in continuity displaying regenerative potential by nerve action potential recording. In these cases, surgery was restricted to either external (12/) or interfascicular neurolysis (10/). Twenty-two cases had no regenerative potential (10/) or showed discontinuity (12/) and thus were reconstructed with autologous sural nerve grafts. In four cases, a reconstructive procedure was intraoperatively abandoned as a result of the large extent of the lesion. Results Thirty-six patients with an adequate follow-up period of at least 18 months were included in this study. Among those with external neurolysis, 73% (eight out of 11) showed a good functional outcome, obviating the need for a kick-up foot brace (M >or= 4). In the interfascicular neurolysis group, 71% (five out of seven) exhibited a similar outcome. In the grafted group, however, only 28% (five out of 18) obtained a functionally useful result dependent on graft length. A graft length under 6 cm led to a functionally useful outcome in 44% of patients (four out of nine) compared with 11% (one out of nine) when the graft length was greater than or equal to 6 cm. In six patients, muscle-tendon transfers were performed, resulting in strong, useful foot lift. Conclusion Peroneal nerve lesions lacking regenerative signs should be explored. A functionally useful result (M >or=4) was achieved in 72% of the patients with either external or internal neurolysis and in 28% of the patients after a nerve graft procedure. Patients in whom nerve surgery failed to reconstitute useful foot lift need to be evaluated for their suitability to undergo a tendon transfer procedure.

✓In this article the authors attempt to raise awareness of the pitfalls and controversial issues in nerve tumor surgery. In a case-guided format, examples of ambiguous findings, inappropriate tumor removal, repeated surgery, and nerve repairs are provided. The authors also discuss the need to establish a correct diagnosis preoperatively and to avoid the erroneous identification of malignant peripheral nerve sheath tumors (MPNSTs). They emphasize that not all of the principles of soft tissue sarcoma treatment protocols are applicable to MPNST. A situation of repeated surgery for supposedly malignant tumor is described, and an outline of the indications for, and an approach to, repair after lesion removal is given.

Management of conducting neuroma-in-continuity in primary surgery for obstetrical brachial plexus palsy (OBPP) is still discussed controversially. We present our experience with intraoperative neurophysiological recordings in the management of lesions in continuity in OBPP.A series of ten children with lesions in continuity of the upper brachial plexus is presented. Due to recordable compound nerve action potentials (CNAPs) and muscle response to motor stimulation across the neuroma, five children underwent external neurolysis of neuroma only (neurolysis group). Due to lack of recordable CNAPs or muscle response, resection of neuroma and interpositional nerve grafting were performed in another five children (resection and grafting group). Functional recovery after at least 30 months of follow-up was assessed.There was a marked difference in functional recovery between the neurolysis and the resection and grafting group. Especially, recovery of shoulder function was disappointing after external neurolysis of conducting neuroma-in-continuity. At the end of follow-up, results of shoulder and elbow function after resection of neuroma followed by interpositional nerve grafting were better without exception.Intraoperative neurophysiological recordings face certain difficulties when used in small children with OBPP. Due to overoptimistic assessment of prognosis after intraoperative CNAP recordings and motor stimulation, the functional results after neurolysis of conducting neuroma-in-continuity are disappointing. Resection of neuroma-in-continuity, conducting or not, offers the best opportunity for maximal functional recovery of the compromised upper limb in OBPP. The role of intraoperative neurophysiological techniques should be confined to the diagnosis of root avulsions.

Surgical decompression and internal fixation of the injured spine have become standard procedures in the management of thoracic and lumbar spine fractures, but their effectiveness on neurological recovery remains controversial. We report on 169 consecutive patients with thoracic and lumbar spine fractures who were treated by reduction, fusion, and internal fixation using transpedicular screw-rod systems. Open decompression was carried out in 67 (39.6%) of them, including all 42 patients (25%) who presented with initial neurological deficits. At least 8 months following surgery, 30 (71%) had neurologically improved by one to three grades on the Frankel scale. Thirteen (59%) out of 22 patients whose initial deficits had been classified as "motor useless" (Frankel grades A to C) could walk, at least with support. Thirteen out of 20 patients with posttraumatic deficit Frankel D ("motor useful") improved to full recovery (Frankel E). In six (3.6%) patients (all from the group of the 127 patients without initial neurological deficits), permanent slight postoperative neurological impairment of one Frankel grade (E to D) was seen, among them two (1.2%) with new minor motor deficit. Neurological outcome was significantly better (p

From January 1999 to May 2003, 316 aneurysms were treated, among them 40 patients (12.7%) over 65 years with subarachnoid haemorrhage (SAH). The results of this sub-group are presented. Mean age was 71 years (range 65–83 years), 40% of the patients were in (Hunt & Hess) grade I–III and 60% grade IV–V. Eighty-five percent of the aneurysms were located in the anterior circulation (35% ACom aneurysms). Nineteen aneurysms were coiled (all basilar tip and small-based ACom aneurysms), two among them subsequently clipped after coil compaction, 18 were initially clipped (most of MCA and all broad-based ACom aneurysms), two wrapped and one trapped. A total of 66.7% of the patients with coiled and 60.0% with clipped aneurysms had been hospitalized in poor condition (Hunt & Hess IV–V). The average follow-up period was 16 months. Overall, 35% of patients fully recovered, 5% returned to normal activity with some deficit, 33% remained dependent and 27% died. All seven patients with MCA aneurysms and intracerebral haematoma were clipped, but died or remained vegetative. Ten of 17 coiled patients (58.8%) had a favourable outcome, compared to 4/11 (36.4%) in the clip group, but two primarily coiled aneurysms rebleld due to coil compaction. The outcome is dependent on the primary Hunt & Hess grade. A total of 48.5% of SAH patients without intracerebral bleeding fully recovered, even patients in poor primary grade. Additional intracerebral haemorrhage is linked to a bad outcome. As primary procedure, the less traumatic coiling seems to be superior to clipping primarily. Better Hunt & Hess grades have a statistically significant chance for a promising outcome.

Shaving of the hair and neurosurgical procedures are almost inseparably connected issues. This may add an additional psychological stress to the patient. Those departments which abandoned pre-operative shaving did not see higher infection rates. From January 1993 to September 1994 we performed 57 cranial procedures without any shaving, among them 5 shunt procedures. We found no disturbances of wound healing or septic complications. Therefore neurosurgical procedures without shaving are recommended for all benign cranial processes if a rapid rehabilitation of the patient to his normal daily life is to be expected.

Arachnoid cysts may present with various symptoms and in different locations. Optimal treatment is still controversial, although cyst fenestration or shunt insertion are recognized as standard procedures. In this retrospective analysis the authors sought to determine which factors influence the outcome after surgery of symptomatic arachnoid cysts.37 patients (24 male, 13 female, mean age 40.2 years) were treated within a ten year period in our institution. Mean follow-up was 39 months; follow-up was done on an ambulatory basis. For analysis patient charts were reviewed and cranial CT scans or MR investigations were examined to determine pre- and postoperative cyst volumes. Clinical outcome was graded into four subgroups using a scale based on the patients self-rating of success. Different factors were studied concerning their influence on outcome.Fenestration was performed in 28 cases, cysto-peritoneal or cysto-atrial shunting in 9 cases. A favourable outcome (subgroups 3 and 4) was achieved in 19 of 28 patients (fenestration) and in 6 of 9 patients (shunting), respectively. Mean reduction of the cyst volumes was 58% after fenestration and 74% after shunting revealing both methods to be effective. Degree of cyst volume reduction correlated significantly with clinical outcome. Patients with infratentorial cysts had more often a favourable outcome. Headache as the only symptom did not influence outcome.Surgery of symptomatic arachnoid cysts resulted in favourable outcome in two thirds of the patients. Both standard procedures, fenestration and shunting, are equally effective for treatment. Factors that influence outcome are the rate of volume reduction and cyst location.

MRI detects small intracranial lesions, but has difficulties in differentiating between tumour, gliosis and edema. (11)C methionine-PET may help to overcome this problem. For its appropriate intra-operative use, it must be integrated into neuronavigation. We present the results of our pilot study with this method.32 patients with 34 intracranial lesions detected by MRI underwent additional (11)C methionine-PET, because the pathophysiological behaviour or the tumour delineation was unclear. All lesions were treated surgically. In 25 patients PET data could be integrated directly into cranial neuronavigation.(11)C methionine uptake was observed in 27/34 lesions, 26 of them were tumours: 14 malignant and 7 benign gliomas, 3 gliomas without further histological typing, one Ewing sarcoma and one non-Hodgkin lymphoma. Only one (11)C methionine positive lesion was non-tumourous: it was staged as post-irradiation necrosis in a patient operated on for a malignant glioma. 3/7 (11)C-methionine negative lesions were classified as gliosis (n=2) and M. Whipple (n=1), but 4/7 were tumours: 2 astrocytomas WHO(degrees)II, 1 DNT and one astrocytoma WHO(degrees)III. The sensitivity of (11)C methionine-PET was 87%, the specificity 75%, the positive predictive value 96% and the negative predictive value 43%. In all tumourous cases with positive tracer uptake the borderline area of the tumour was better defined by (11)C methionine-PET than by MRI.A positive (11)C methionine-PET is highly suspicious of a tumour, a negative one does not exclude it. (11)C methionine-PET seems to be more sensitive than MRI for differentiating between tumour and edema or gliosis. Simultaneous integration MRI and (11)C methionine-PET into cranial neuronavigation can facilitate cross total tumour removal in glioma surgery.

OBJECTIVEOptimal treatment of elderly patients with Type II odontoid fractures is controversial. Suggestions vary between conservative management and different types of early surgery. Recent data confirm that early surgery may be warranted because conservative treatment has a high rate of failure in the elderly.METHODSWe performed a case-control study of 27 patients with Type II odontoid fracture who were treated with anterior odontoid double-screw fixation at our institution. The aim of the study was to determine whether patients aged 70 years or older have a less favorable outcome than younger patients with this operative technique. Cases were defined as patients with Type II odontoid fracture aged 70 years or older. All patients younger than 70 years served as controls.RESULTSThere were 15 patients aged 70 years or older (Group 1) and 12 patients younger than 70 years of age (Group 2). Mean follow-up was 16.6 months. Mean interval between fracture and surgery was 10 days. All patients were treated with anterior odontoid screw fixation by use of two compression screws. Fusion rates were 73% in Group 1 and 75% in Group 2. Additional dorsal stabilization was performed in 13% of cases in Group 1 and 17% of cases in Group 2. Complications occurred in 20% of cases in Group 1 and 8% of cases in Group 2. The only death occurred in Group 1, leading to 7% mortality in this group. Neurological status at admission and after treatment was similar in both groups. Statistical analysis did not reveal significant differences between groups for the factors studied.CONCLUSIONOutcome after anterior odontoid screw fixation is not affected by patient age. Slightly higher rates of medical complications did not reach statistical significance. Because conservative management of odontoid fractures in the elderly has a high rate of failure, anterior stabilization for Type II odontoid fractures can be recommended.

The objective of the investigation was to prevent the stigmatizing effect of a totally or partially shaved head with openly visible signs of a head operation, easing the reintegration of the patient into his daily life. After extended surface cleaning with a colourless, regular skin disinfection liquid (undyed isopropanol/dibrom/propylenglycol solution) the hair was combed apart from the incision line before draping. Wound closure was performed as usual, taking care to remove meticulously hair from the wound. To aid closure we made use of a 20% chlorhexidine jelly that holds the hair away from the incision. A neomycin ointment served for sealing the wound surface, no further dressing being used. After 215 cranial neurosurgical operations, among them 63 for tumours, 33 stereotactic procedures 18 shunt, 55 for torticollis and 46 other operations performed without shaving the hair, we saw one wound infection (0.5%). This percentage corresponds very well to our general infection rate of 0.6%. All patients very much appreciated the offered opportunity and the result. If the objective is to give patients a psychological advantage by preventing a partially bald head we think one can safely refrain from the shaving procedure without risking a higher infection rate.

Objective The goals of the study were to investigate the value of intraoperative electrically evoked nerve action potentials (NAPs) in the surgical treatment of traumatic peripheral nerve injuries (nerve lesions in continuity). Methods Sixty-four patients with 76 traumatic nerve lesions in continuity were investigated intraoperatively by stimulating and recording NAP from the whole nerve across the suspected lesion site. Among the 76 nerves (nerve lesions) were 43 with incomplete and 33 with complete loss of function. In cases (nerves) with complete loss of function (n = 33), the surgical procedure (external neurolysis, internal neurolysis, or nerve repair) was performed according to the microscopic aspect of the nerve and the result of the intraoperative electrophysiological testing. In cases (nerves) with incomplete loss of function (n = 43), the surgical procedure was performed solely according to the microscopic aspect of the nerve and independently from the result of the intraoperative electrophysiological testing. Results Of 43 nerves with incomplete loss of function, we were able to record reproducible NAPs in 41 (95%) across the lesion site, thus demonstrating a high reliability of the method. Of 33 nerves with complete loss of function, a reproducible NAP could be recorded only in 3. Assuming an axonotmetic lesion in regeneration, we did nothing else on the nerve with excellent clinical results (full recovery). Of the remaining nerves with no NAP, 24 showed a caliber shift of the nerve (in 20 cases a thickening of the nerve, suggesting a neuroma in continuity). A grafting procedure was performed, and the histological evaluation revealed a neurotmetic lesion. However, in six patients with no NAP, there was no clear caliber shift of the nerve. The epineurium was opened and an internal neurolysis performed showing fascicles in continuity. Three patients had good and three had partial (but useful) recovery. Conclusions In nerve lesions in continuity with complete loss of nerve function, intraoperative NAPs are able to detect axonotmetic lesions in regeneration. Thus, unnecessary further surgical procedures can be avoided. On the other end of the spectrum, no recordable NAP together with a caliber shift of the nerve (suggesting a neuroma in continuity) may facilitate the surgeon's decision for a grafting procedure without a time-consuming internal neurolysis. But there is also evidence from our data that not every nerve lesion in continuity without a NAP needs to be grafted.

16 patients with peripheral nerve neurinomas (benign schwannomas) were operated upon in our hospital between 1990–1995. The largest tumours were found on proximal segments of peripheral nerves (brachial plexus: 15 cm, sciatic nerve: 20 cm). The average duration of symptoms was 1 1/2 years (range: 3 months — 15 years). Pain or painfull paraesthesias were the main complaints (13/16). Postoperatively, 9 patients were painfree while 4 improved. Similarly, neurological deficits were favourably influenced by the operation: Out of 5 patients with motor deficits 4 had complete, 1 patient had partial recovery. One out of 4 patients with sensory deficits had complete recovery, 2 remained unchanged, while 1 worsened. Two patients developed new motor and 6 patients new sensory deficits, which (in the course of time) did not disappear completely. New deficits developed predominantly in patients with large tumours or longstanding symptoms. Tumour recurrences were not seen during the follow-up period of 23 months. Our findings revealed that in the majority of cases peripheral nerve neurinomas can be excised with good results. Patients should be treated by a neurosurgeon with special expertise in peripheral nerve surgery. The patient should be thoroughly informed pre-operatively about any eventual new neurological deficits following surgery.

Intra-operative direct root-SEPs combined with evoked muscle action potentials (EMAPs) from neck muscles are presented as helpful tools for evaluation of anterior and/or posterior spinal root avulsion from the spinal cord during surgical management of brachial plexus stretch injuries.

If botulinum toxin fails in the treatment of cervical dystonia, selective peripheral denervation is now accepted as the best surgical option. Despite the very promising results, however, there is still a substantial group of patients who do not benefit from this procedure. Positive response to prior botulinum toxin therapy seems to be a very good predictor of outcome after selective peripheral denervation (P < 0.01). The meaning of the histological findings of the resected nerves is uncertain. Patients with histologically proven pathological nerves do not seem to benefit more than patients with histological normal ones (P < 0.30).

An 11-year-old boy affected by neurofibromatosis type 1 is presented with severely impaired vision on the right eye (0.1). MRI demonstrated a 2.3 x 1.8 cm tumour of the optic chiasma. After open biopsy cytogenetic analysis was performed on primary cultures of this optic glioma (grade I). A clonal translocation t(10;21)(q21.2;21.1) was detected in 66% of the metaphases analysed. The boy received fractioned irradiation with a total tumour dose of 60 Gy. The ultimate MRI taken 18 months after radiotherapy showed no residual tumour. The vision on the right improved to 0.2, but decreased on the left to 0.6. The patient attends high school with no impairment in his daily life.

In 28 patients with spasmodic torticollis dorsal branches of the cervical nerves C1–6, and in 25 of these patients fascicles of the contralateral accessory nerve were investigated by light and electron microscopy. Significant changes were noted in 15 patients. The alterations were not seen or were less prominent in the 5 control cases studied for comparison. Semiquantitative evaluation of light microscopic findings revealed in 12 cases prominent and numerous Renaut bodies; in 9 cases evidence of regeneration (in 3 of these postoperatively); and in 11 cases disproportionately thin myelin sheaths in relation to axon calibers. In conjunction with endoneurial edema and thickening of the perineurium, these changes were suggestive of compression neuropathy. Whether these changes were the cause, or a side effect of the abnormal muscle contractions in spasmodic torticollis could not be elucidated. Peripheral nerve compression, however, may trigger abnormal activity in the peripheral part of the involved interneuronal circuits and may, thus, be considered as one of the many possible causes of spasmodic torticollis.