Search

The effects of inhaled and intravenous application of a guanylate cyclase stimulator (BAY 41–8543) on pulmonary vascular resistance (PVR) and cardiac output (CO) were investigated in an experimental model of septic shock. Following induction of septic shock, anaesthetized pigs (n=31) were randomly place into two groups receiving different interventions. Animals in the first group received intravenous BAY 41–8543 (0.6 mg), inhalative BAY 41–8543 (6 mg) or a placebo. In the second group, the dosage of BAY 41–8543 was increased two-fold or combined with inhalation of nitric oxide (iNO). Intravenous and inhaled administration of BAY 41–8543 resulted in a significantly (P

Background:The authors hypothesized that goal-directed hemodynamic therapy, based on the combination of functional and volumetric hemodynamic parameters, improves outcome in patients with cardiac surgery. Therefore, a therapy guided by stroke volume variation, individually optimized global end-diastolic volume index, cardiac index, and mean arterial pressure was compared with an algorithm based on mean arterial pressure and central venous pressure.Methods:This prospective, controlled, parallel-arm, open-label trial randomized 100 coronary artery bypass grafting and/or aortic valve replacement patients to a study group (SG; n = 50) or a control group (CG; n = 50). In the SG, hemodynamic therapy was guided by stroke volume variation, optimized global end-diastolic volume index, mean arterial pressure, and cardiac index. Optimized global end-diastolic volume index was defined before and after weaning from cardiopulmonary bypass and at intensive care unit (ICU) admission. Mean arterial pressure and central venous pressure served as hemodynamic goals in the CG. Therapy was started immediately after induction of anesthesia and continued until ICU discharge criteria, serving as primary outcome parameter, were fulfilled.Results:Intraoperative need for norepinephrine was decreased in the SG with a mean (±SD) of 9.0 ± 7.6 versus 14.9 ± 11.1 µg/kg (P = 0.002). Postoperative complications (SG, 40 vs. CG, 63; P = 0.004), time to reach ICU discharge criteria (SG, 15 ± 6 h; CG, 24 ± 29 h; P < 0.001), and length of ICU stay (SG, 42 ± 19 h; CG, 62 ± 58 h; P = 0.018) were reduced in the SG.Conclusion:Early goal-directed hemodynamic therapy based on cardiac index, stroke volume variation, and optimized global end-diastolic volume index reduces complications and length of ICU stay after cardiac surgery.

The aim of this study was to assess whether thermodilution-derived parameters of right and left ventricular cardiac function (right ventricular ejection fraction, global ejection fraction, cardiac function index) are able to track changes of cardiac contractile function and whether they are influenced by substantial preload reduction.Prospective animal study.University-affiliated animal research laboratory.Domestic pigs.Sixteen domestic pigs were studied. Right ventricular ejection fraction, global ejection fraction, and cardiac function index were compared to direct measurement of left ventricular rate of maximum systolic pressure rise and the left ventricular rate of maximum systolic pressure rise corrected to preload. Measurements were done with normal cardiac function during normo- and hypovolemia. Thereafter, cardiac function was impaired by continuous infusion of verapamil and measurements were repeated during normo- and hypovolemia (withdrawal of blood 20 mL kg body weight).With normal cardiac function, hypovolemia led to a significant decrease of right ventricular ejection fraction from 36.7% ± 6.6% to 29.8% ± 5.8% (p.001), global ejection fraction from 40.5% ± 6.2% to 33.6% ± 7.6% (p.001), and the left ventricular rate of maximum systolic pressure rise from 2104 ± 390 mm Hg sec to 1297 ± 438 mm Hg sec (p.001). Cardiac function index (8.92 ± 2.20 min to 7.93 ± 1.54 min) and the left ventricular rate of maximum systolic pressure rise corrected to preload (18.2 ± 4.7 mm Hg sec mL to 15.2 ± 4.3 mm Hg sec mL) did not change significantly. Infusion of verapamil led to a significant reduction of right ventricular ejection fraction, global ejection fraction, cardiac function index, the left ventricular rate of maximum systolic pressure rise, and the left ventricular rate of maximum systolic pressure rise corrected to preload (p.001). Now, hypovolemia led to a significant decrease of right ventricular ejection fraction (29.1% ± 4.6% to 24.9% ± 5.9%; p.001), global ejection fraction (37.1% ± 4.7% to 31.9% ± 3.9%; p.05), cardiac function index (7.58 ± 1.02 to 6.27 ± 1.19 min; p.05), and the left ventricular rate of maximum systolic pressure rise (733 ± 141 mm Hg sec to 426 ± 108 mm Hg sec; p.05). Only the left ventricular rate of maximum systolic pressure rise corrected to preload did not change significantly (6.7 ± 1.3 mm Hg sec mL to 4.6 ± 1 mm Hg sec mL; p.05).Right ventricular ejection fraction, global ejection fraction, and cardiac function index enable detection of changes in load-independent, intrinsic cardiac contractility. Importantly, they also reflect changes of contractile function caused by substantial decrease of preload, emphasizing the importance of assessing both cardiac contractile function in coherence with cardiac preload to differentiate between reduced intrinsic contractility and hypovolemia.

Predicting the response of cardiac output (CO) to volume administration remains difficult, in particular in patients with acutely compromised cardiac function, where, even small amounts of i.v. fluids can lead to volume overload. We compared the ability to predict volume responsiveness of different functional haemodynamic parameters, such as pulse pressure variation (PPV), stroke volume variation (SVV), the static preload parameter right atrial pressure (RAP), and global end-diastolic volume (GEDV) with the recently proposed respiratory systolic variation test (RSVT) in acutely impaired cardiac function.In 13 mechanically ventilated pigs, cardiac function was acutely reduced by continuous application of verapamil to reach a decrease in peak change of left ventricular pressure over time (dP/dt) of 50%. After withdrawal of 20 ml kg(-1) BW blood to establish hypovolaemia, four volume loading steps of 7 ml kg(-1) BW using the shed blood and 6% hydroxyethylstarch 130/0.4 were performed. Volume responsiveness was considered as positive, if CO increased more than 10%.Receiver operating characteristic curve analysis revealed an area under the curve (AUC) of 0.88 for the RSVT, 0.84 for PPV, 0.82 for SVV, 0.78 for RAP, and 0.77 for GEDV.Functional parameters of cardiac preload, including the RSVT, allow prediction of fluid responsiveness in an experimental model of acutely impaired cardiac function.

Background: The authors hypothesized that goal-directed hemodynamic therapy, based on the combination of functional and volumetric hemodynamic parameters, improves outcome in patients with cardiac surgery. Therefore, a therapy guided by stroke volume variation, individually optimized global end-diastolic volume index, cardiac index, and mean arterial pressure was compared with an algorithm based on mean arterial pressure and central venous pressure. Methods: This prospective, controlled, parallel-arm, open-label trial randomized 100 coronary artery bypass grafting and/or aortic valve replacement patients to a study group (SG; n = 50) or a control group (CG; n = 50). In the SG, hemodynamic therapy was guided by stroke volume variation, optimized global end-diastolic volume index, mean arterial pressure, and cardiac index. Optimized global end-diastolic volume index was defined before and after weaning from cardiopulmonary bypass and at intensive care unit (ICU) admission. Mean arterial pressure and central venous pressure served as hemodynamic goals in the CG. Therapy was started immediately after induction of anesthesia and continued until ICU discharge criteria, serving as primary outcome parameter, were fulfilled. Results: Intraoperative need for norepinephrine was decreased in the SG with a mean (SD) of 9.0 +/- 7.6 versus 14.9 +/- 11.1 mu g/kg (P = 0.002). Postoperative complications (SG, 40 vs. CG, 63; P = 0.004), time to reach ICU discharge criteria (SG, 15 +/- 6 h; CG, 24 +/- 29 h; P

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.

Object.Surgical therapy for traumatic brachial plexus lesions is still a great challenge in the field of peripheral nerve surgery. The aim of this study was to present the results of different surgical interventions in patients with this lesion type.Methods.One hundred thirty-four patients with traumatic brachial plexus lesions underwent surgery between January 1991 and September 1999. In more than 50% of the patients, injury was caused by a motorbike accident. Patients underwent surgery a mean of 6.3 months posttrauma. The following surgical techniques were applied: neurolysis for nerve lesions in continuity (27 cases), grafting for lesions in discontinuity (149 cases), and neurotization for root avulsions (67 cases). Sixty-five patients were evaluated for at least 30 months (mean follow up 42.1 months) after surgery.Function was graded using the Louisiana State University Health Sciences Center classification system. Only 2% of the patients had Grade 3 or better function preoperatively, increasing to 52% postoperatively. The effect of surgical measures on the functional results for different muscles were compared (supra- or infraspinatus, deltoid, biceps, and triceps muscles); the best results were obtained for biceps muscle function (57% of patients with Medical Research Council Grades M3–M5 function). Graft reconstruction yielded a better outcome than neurotization. Surgery within 5 months posttrauma clearly resulted in improved recovery of motor function compared with later interventions. Sural nerve grafts (monofascicular nerves) showed better results.Conclusions.The results of neurosurgical interventions for brachial plexus lesions are satisfactory, especially when the operation is performed between 3 and 6 months after trauma.

Im Rahmen der mikrochirurgischen Bandscheibenchirurgie besteht die ubliche Vorgehensweise darin, neben dem Bandscheibensequester auch die lockeren oder degenerierten Nukleusanteile zu entfernen. Ob dies in jedem Fall erforderlich ist, ist umstritten. Ziel der vorliegenden Arbeit ist es, diese Fragestellung anhand klinischer Resultate naher zu untersuchen. Im Rahmen einer prospektiven Untersuchung wurden von 149 Patienten nach ausschlieslicher Sequestrektomie pra- und intraoperative Daten erfasst sowie der klinische Verlauf im Mittel nach 2,3 Jahren bestimmt. Besonderes Augenmerk wurde auf die aktuelle Schmerzsymptomatik, Funktionskapazitat und evtl. erfolgte erneute spinale Operationen gelegt. An fruhen Komplikationen zeigte sich lediglich bei einem Patient eine oberflachliche Wundentzundung, die konservativ behandelt wurde. Beim Follow-up zeigt sich bei 62% der Patienten ein sehr gutes Behandlungsergebnis, weitere 25% der Patienten sind im Vergleich zu praoperativ deutlich beschwerdegebessert. Lediglich 13% zeigen keinen eindeutigen Behandlungserfolg. Gemessen an der visuellen Analogskala (VAS) sind beim Follow-up Bein- und Ruckenschmerzen etwa gleich intensiv. Die durchschnittliche Funktionskapazitat betragt 74%, gemessen unter Verwendung des Funktionsfragebogens Hannover fur Ruckenschmerzen (FFbH-R). Wahrend der Nachbeobachtungszeit wurden 4 von 149 Patienten nochmals im selben Wirbelsaulensegment operiert, in 2 Fallen handelte es sich hierbei um eine Rezidivdiskushernie (1,3%). Die ausschliesliche Sequestrektomie zeigt im Vergleich zur mikrochirurgischen Standarddiskektomie vergleichbare Resultate. Insbesondere findet sich keine vermehrte Rezidivneigung, wie dies oft befurchtet und in der Vergangenheit auch publiziert wurde. Moglicherweise liegt dies an den strengen Selektionskriterien zur Sequestrektomie, die in der hier untersuchten Patientengruppe konsequent eingehalten wurden. Ob die ausschliesliche Sequestrektomie eine teilweise zusatzlich bestehende Ruckenschmerzkomponente genugend effektiv behandelt, sollte durch kontrollierte Studien naher untersucht werden.

Today, posterior stabilization of the cervical spine is most frequently performed by lateral mass screws or spinous process wiring. These techniques do not always provide sufficient stability, and anterior fusion procedures are added secondarily. Recently, transpedicular screw fixation of the cervical spine has been introduced to provide a one-stage stable posterior fixation. The aim of the present prospective study is to examine if cervical pedicle screw fixation can be done by low risk and to identify potential risk factors associated with this technique. All patients stabilized by cervical transpedicular screw fixation between 1999 and 2002 were included. Cervical disorders included multisegmental degenerative instability with cervical myelopathy in 16 patients, segmental instability caused by rheumatoid arthritis in three, trauma in five and instability caused by infection in two patients. In most cases additional decompression of the spinal cord and bone graft placement were performed. Pre-operative and post-operative CT-scans (2-mm cuts) and plain X-rays served to determine changes in alignment and the position of the screws. Clinical outcome was assessed in all cases. Ninety-four cervical pedicle screws were implanted in 26 patients, most frequently at the C3 (26 screws) and C4 levels (19 screws). Radiologically 66 screws (70%) were placed correctly (maximal breach 1 mm) whereas 20 screws (21%) were misplaced with reduction of mechanical strength, slight narrowing of the vertebral artery canal (

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.

Einleitung Ziel war es, die Anzahl und Art iatrogener Verletzungen an einem vergleichsweise aktiven Zentrum fur periphere Nervenoperationen wahrend eines Zeitraumes von 13 Jahren zu analysieren.

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.

Object. Botulinum toxin injections are the best therapeutic option in patients with spasmodic torticollis. Although a small number of patients do not benefit from such therapy, the majority respond well but may develop antibodies to the toxin after repeated applications. In those termed primary nonresponders, no improvement related to botulinum toxin has been shown. In patients in whom no response was shown and those in whom resistance to the therapy developed, selective peripheral denervation is a neurosurgical option. Methods. Between June 1988 and August 2001, 155 patients underwent selective peripheral denervation. Surgery was performed at a mean of 8.5 years after the onset of symptoms (range 0.5–37 years). The mean age of the patients at the onset of dystonia was 39.7 years (range 17–77 years). For evaluation of results, patients' responses were assessed. Results were obtained in 140 patients in whom the follow-up period ranged from 3 to 124 months (mean 32.8 months): 18 reported complete relief of their symptoms, 50 significant relief, and 34 moderate relief; 19 noted only minor relief and the remaining 19 no improvement. The results differ substantially when compared with those previously demonstrated in patients who received botulinum toxin injections. Although 80% of the secondary nonresponders were satisfied with the result of surgery, only 62% of the primary nonresponders considered the operation helpful. There were no major side effects. The recurrence rate was 11%. Conclusions. The injection of botulinum toxin should be the first-choice treatment. If surgery is required, selective peripheral denervation provides the best results and has the fewest side effects compared with all surgical options.

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.

Background Monitoring cardiac output (CO) is important to optimize hemodynamic function in critically ill patients. The prevalence of aortic valve insufficiency (AI) is rising in the aging population. However, reliability of CO monitoring techniques in AI is unknown. The aim of this study was to investigate the impact of AI on accuracy, precision, and trending ability of transcardiopulmonary thermodilution-derived COTCPTD in comparison with pulmonary artery catheter thermodilution COPAC. Methods Sixteen anesthetized domestic pigs were subjected to serial simultaneous measurements of COPAC and COTCPTD. In a novel experimental model, AI was induced by retraction of an expanded Dormia basket in the aortic valve annulus. The Dormia basket was delivered via a Judkins catheter guided by substernal epicardial echocardiography. High (HPC), moderate (MPC) and low cardiac preload conditions (LPC) were induced by fluid unloading (20 ml kg-1 blood withdrawal) and loading (subsequent retransfusion of the shed blood and additional infusion of 20 ml kg-1 hydroxyethyl starch). Within each preload condition CO was measured before and after the onset of AI. For statistical analysis, we used a mixed model analysis of variance, Bland-Altman analysis, the percentage error and concordance analysis. Results Experimental AI had a mean regurgitant volume of 33.6 ± 12.0 ml and regurgitant fraction of 42.9 ± 12.6%. The percentage error between COTCPTD and COPAC during competent valve function and after induction of substantial AI was: HPC 17.7% vs. 20.0%, MPC 20.5% vs. 26.1%, LPC 26.5% vs. 28.1% (pooled data: 22.5% vs. 24.1%). The ability to trend CO-changes induced by fluid loading and unloading did not differ between baseline and AI (concordance rate 95.8% during both conditions). Conclusion Despite substantial AI, transcardiopulmonary thermodilution reliably measured CO under various cardiac preload conditions with a good ability to trend CO changes in a porcine model. COTCPTD and COPAC were interchangeable in substantial AI.

Iatrogenic nerve injuries can result from direct surgical trauma, mechanical stress on a nerve due to faulty positioning during anesthesia, the injection of neurotoxic substances into a nerve, and other mechanisms. Treating physicians should know the risk factors and the procedure to be followed when an iatrogenic nerve injury arises.This review is based on pertinent articles retrieved by a selective search in PubMed and on the authors' own data from the years 1990-2012.In large-scale studies, 25% of sciatic nerve lesions that required treatment were iatrogenic, as were 60% of femoral nerve lesions and 94% of accessory nerve lesions. Osteosyntheses, osteotomies, arthrodeses, lymph node biopsies in the posterior triangle of the neck, carpal tunnel operations, and procedures on the wrist and knee were common settings for iatrogenic nerve injury. 340 patients underwent surgery for iatrogenic nerve injuries over a 23-year period in the District Hospital of Günzburg (Neurosurgical Department of the University of Ulm). In a study published by the authors in 2001, 17.4% of the traumatic nerve lesions treated were iatrogenic. 94% of iatrogenic nerve injuries occurred during surgical procedures.A thorough knowledge of the anatomy of the vulnerable nerves and of variants in their course can lessen the risk of iatrogenic nerve injury. When such injuries arise, early diagnosis and planning of further management are the main determinants of outcome. If adequate nerve regeneration does not occur, surgical revision should optimally be performed 3 to 4 months after the injury, and 6 months afterward at the latest. On the other hand, if postoperative high resolution ultrasound reveals either complete transection of the nerve or a neuroma in continuity, surgery should be performed without any further delay. If the surgeon becomes aware of a nerve transection during the initial procedure, then either immediate end-to-end suturing or early secondary management after three weeks is indicated.

Object. Failed-back syndrome is still an unsolved problem. Use of ADCON-L gel, already commercially available, has been proven to reduce postoperative scarring in animal experiments. The authors of two controlled clinical studies have also shown positive results when applying the gel. They did not, however, establish patient-oriented endpoints. The authors report a study of ADCON-L in which they focus on patient-oriented endpoints. Methods. Patients with lumbar disc herniation were randomized to an ADCON-L—treated or control group. Therapeutic success was evaluated using the validated Hannover Questionnaire on Activities of Daily Living (FFbH) 6 months after surgery. The study took place between November 14, 1996, and April 20, 1998, in eight neurosurgical centers in Germany. A total of 398 patients was recruited; 41 patients dropped out during follow up. The mean functional FFbH score (100 points = all activities are possible without problem; 0 points = no activity is possible) was 78.5 points in the ADCON-L—treated group compared with 80 points in the control group. Furthermore, in terms of secondary outcome variables, the ADCON-L group did not have an advantage over the control group. Only the mean magnetic resonance imaging score showed a slight advantage of ADCON-L over the control group. Conclusions. The authors found no positive effect of treatment with ADCON-L gel in patients in whom one-level lumbar microdiscectomy was performed. Because of its rather large sample size and its homogeneity, the study had sufficient power to detect even small differences between the two groups.

Object. The purpose of this study was to discover the number and types of iatrogenic nerve injuries that were surgically treated during a 9-year period at a relatively busy nerve center. The specific nerves involved, their sites of injury, and the mechanisms of injury were also documented. Methods. The authors retrospectively evaluated the surgically treated iatrogenic lesions by reviewing case histories, operative reports, and follow-up notes in 722 cases of trauma. These cases were treated between January 1990 and December 1998 because of pain, dysesthesias, and sensory and/or motor deficits. Iatrogenic injury was a much larger category of trauma than predicted. One hundred twenty-six (17.4%) of the 722 surgically treated cases were iatrogenic in origin. Most of these injuries occurred during a previous operation. To a major extent, nerves of the extremities were affected, and a relatively large number of injuries occurred in the neck and groin. Incidence was highest in the spinal accessory nerve (14 cases), the common peroneal nerve (11 cases), the superficial radial nerve (10 cases), the genitofemoral nerve branches (10 cases), and the median nerve (nine cases). At least two thirds of the patients did not undergo surgery for the iatrogenic injury within an optimal time interval due to delayed referral. Follow-up data were available in 97 of the 126 patients. Surgical outcomes demonstrated improvement in 70% of patients. Operative results were especially favorable in patients suffering from iatrogenic injuries to the accessory and superficial sensory radial nerves. Conclusions. Iatrogenic injuries should be corrected in a timely fashion just like any other traumatic injury to nerve.

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.

Purpose Identification of the precentral gyrus can be difficult in patients with brain tumors. The purpose of the current study was to evaluate the clinical usefulness of functional MRI (fMRI) in identifying motor cortex and speech areas as a part of preoperative neurosurgical planning. Method fMRI was performed using a 1.5 T MR unit in 41 patients with brain tumors. The motor paradigm was finger tapping and foot movement, whereas the language paradigm consisted of a two word semantic test. Statistical analysis of the data was done using the Kolmogorow-Smirnow test. Plots of signal intensities over time were created. Results The precentral gyrus was identified in 38 of 41 patients. In two patients, fMRI was not of acceptable quality due to motion artifacts. Speech areas were localized in 33 patients. In a typical clinical setting, the value of the method was graded “high.” Conclusion fMRI`s efficacy in the preoperative localization of language and motor areas is high. The method should become a routine adjunct for preoperative evaluation of brain tumors in the near future.

Berichtet wird uber ein Meningeom mit kartilaginaren Anteilen im Bereich des rechten Keilbeinflugels bei einer 74jahrigen Frau. Histologisch fanden sich neben Abschnitten eines typischen meningothelialen Meningeoms zahlreiche kartilaginare Gewebsinseln sowie chondroide, offenbar intermediar (meningothelial/kartilaginar) differenzierte Bezirke. Die kartilaginaren Tumorareale zeigten niedrigere MIB1-Markierungsindizes als die typischen Meningeomabschnitte, die eine fokal gesteigerte Proliferationstendenz aufwiesen. Solche Geschwulste werden in der aktuellen WHO-Klassifikation zu den metaplastischen Meningeomen gerechnet und spiegeln die Fahigkeit der Meningeomzellen zur mesenchymalen Differenzierung wider. Metaplastische Meningeome konnen unterschiedliche (xanthomatose, ossare, lipomatose, kartilaginare etc.) Metaplasien aufweisen. Ausgedehnte Knorpelmetaplasien sind sehr selten. Der Nachweis typischer Meningeomareale ist der diagnostische Schlussel zu dieser Meningeomvariante.

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.

Two new ways to reduce the edge drop are being investigated both theoretically and in rolling trials. The edge drop control cooling system (EDC cooling) produces a crown shape with the aid of three cooling beams arranged on stand-exit side that, on the one hand, feature a very fine spray pattern distribution in the strip edge area and, on the other hand, are applied with differently tempered cooling medium, allowing the edge drop to be reduced. The EDC rolls are more flexible in the strip edge area than in the remaining part of the barrel. The thus created heavier flattening is, on the one hand, sufficiently large and, on the other hand, also excellently suited by its characteristic property to compensate the edge drop. The effects of both systems were evidenced during comprehensive rolling trials in the first stand of a 2-stand DCR cold tandem mill. For these trials 52 coils of annealed tin plate were used. With the aid of the EDC system, the strip thickness in the immediate strip edge area could be increased by up to 4 % of the nominal thickness.

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.

Fragestellung: Geburtstraumatische Lasionen des Plexus brachialis treten in 0,6–2,5‰ aller Geburten auf. 80–95% dieser Lasionen bilden sich spontan zuruck. Sollte keine spontane Funktionsruckkehr innerhalb der ersten 6 Monate eintreten, muste nach entsprechender Diagnostik, wie elektrophysiologische und myelocomputertomographische Untersuchungen eine operative Freilegung des Plexus brachialis erfolgen. Methode: In einem Zeitraum von 5 Jahren haben wir 7 Kinder mit postpartaler Plexuslasion unter 99 operativ versorgten Plexuslasionen behandelt. 6/7 Kindern zeigten praoperativ Wurzelausrisse. Bei 2 Kindern wurde eine Neurotisation, bei 4 eine autologe Transplantation und beim letzten eine ausere Neurolyse des Plexus brachialis vorgenommen. Ergebnisse: Bisher wurden nur 3/7 Kindern uber einen langeren Zeitraum (26–42 Monate) nachuntersucht. Alle transplantierten Nerven zeigten klinisch eine Reinnervation. Eine Wiederherstellung der normalen Funktion war durch begleitende Wurzelausrisse limitiert. Schlusfolgerungen: Wir empfehlen als optimalen Zeitpunkt fur die Operation den Zeitraum zwischen dem 6. und 9. Monat. Um optimale Ergebnisse bei diesen Kindern zu erzielen, mus sich zunachst eine intensive krankengymnastische Behandlung anschliesen und spater sollte die Option fur Muskeltransfers und orthopadische Operationen gewahrleistet sein.

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.

The authors hypothesized that goal-directed hemodynamic therapy, based on the combination of functional and volumetric hemodynamic parameters, improves outcome in patients with cardiac surgery. Therefore, a therapy guided by stroke volume variation, individually optimized global end-diastolic volume index, cardiac index, and mean arterial pressure was compared with an algorithm based on mean arterial pressure and central venous pressure.This prospective, controlled, parallel-arm, open-label trial randomized 100 coronary artery bypass grafting and/or aortic valve replacement patients to a study group (SG; n = 50) or a control group (CG; n = 50). In the SG, hemodynamic therapy was guided by stroke volume variation, optimized global end-diastolic volume index, mean arterial pressure, and cardiac index. Optimized global end-diastolic volume index was defined before and after weaning from cardiopulmonary bypass and at intensive care unit (ICU) admission. Mean arterial pressure and central venous pressure served as hemodynamic goals in the CG. Therapy was started immediately after induction of anesthesia and continued until ICU discharge criteria, serving as primary outcome parameter, were fulfilled.Intraoperative need for norepinephrine was decreased in the SG with a mean (±SD) of 9.0 ± 7.6 versus 14.9 ± 11.1 µg/kg (P = 0.002). Postoperative complications (SG, 40 vs. CG, 63; P = 0.004), time to reach ICU discharge criteria (SG, 15 ± 6 h; CG, 24 ± 29 h; P0.001), and length of ICU stay (SG, 42 ± 19 h; CG, 62 ± 58 h; P = 0.018) were reduced in the SG.Early goal-directed hemodynamic therapy based on cardiac index, stroke volume variation, and optimized global end-diastolic volume index reduces complications and length of ICU stay after cardiac surgery.