Clinical Neuroscience

[Removal of multiple thoracic dumbbell tumours through combined hemi-semi laminectomy and minimal invasive paraspinal approach]

PAPP Zoltán

JULY 22, 2009

Clinical Neuroscience - 2009;62(07-08)

[One third of the primary spinal tumours are neurinomas. These tumours most often located intraduralyextramedullary, but 15-25 percent of the cases, the tumour extends to the paraspinal region through the neuroforamina. Spinal manifestation of Schwann-cell tumours, usually neurofibromas, can be seen in neurofibromatosis. 31 years old female patient, suffering from NF1 was operated on with a Th 3-6 and Th 10-11 dumbbell tumours. At the first step the tumour mass, located in the spinal canal, was resected through a partial hemilaminectomy. At the second operation the extraspinal tumour was resected through a minimal invasive paraspinal approach. The author present the combined use of minimal invasive spine surgical technics and discuss the benefits and disadvantages of these approaches, compared to the standard surgical procedures.]

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[Surgery of the Pediatric Spine]

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[Acute disseminated encephalomyelitis in childhood]

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[Background and purpose - Acute disseminated encephalomyelitis is a rare inflammatory demyelinating disorder often preceded by infection or vaccination. The purpose of the study was the systematic analysis of clinical, radiological and microbiological profiles of children treated at Szent László Hospital, and the comparison of findings with literature data. Methods - Demographic, infectological, clinical, radiological, laboratory and virological data of patients treated and followed-up between 1-Jan-1998 and 30-June-2008 were reviewed and analysed. Results - 19 children met diagnostic criteria. Their mean age was 6.8 years. A prodromal illness - mostly febrile viral infection, upper respiratory infection or chickenpox - preceded neurological symptoms in 17 patients. All had polysymptomatic encephalopathy, 2 children had spinal symptoms. The cerebrospinal fluid was abnormal in all but one. A viral etiology was definite in 7 and probable in 8 cases. MRI disclosed white matter changes in 18, cortical and deep gray matter in 16, cerebellar in 6, brain stem in 14 and spinal cord changes in 2 cases. Repeat MRI performed mean 4 months later showed complete resolution in 6 and partial resolution in 11 patients. 13 patients received high-dose methylprednisolone, 2 of whom were also treated with plasma exchange and 1 with immunoglobulin. 9 children required mechanical ventilation. 2 patients died, 10 recovered without and 7 with sequelae. 2 patients developed further demyelinating events: multiple sclerosis and multiphasic disseminated encephalomyelitis, respectively. Conclusion - Clinical, radiological and follow-up results were similar to those published in literature however, triggering viruses were identified in a larger proportion of cases.]

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[The case of a 9-year old boy is presented in this article who developed a rare fungal infection of central nervous system. The histopathologic examination has revealed mucormycosis. The diagnosis wasn’t confirmed microbiologically as the culture and PCR were negativ. After the iv administered Amphotericin B lipid complex the MR images of the brain have improved. The mucormycosis classically develops in immunodeficient patients and presents an acute, fulminant, mostly lethal infection. This case is very unusual, because the chronic, isolated CNS mucormycosis has slowly developed in immuncompetent patient and only one symptom was the long existing headache. The aim of this paper is reporting the case history and to find out the possible way of infection.]

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[Combined anterior and posterior approach to the tumours of the cervicothoracic junction: our experience]

BANCZEROWSKI Péter, LIPÓTH László, VERES Róbert

[Introduction - In the past, surgery of the pathologies of cervicothoracic junction carried high risk. Better knowledge of the anatomical situation and the increasing experience with anterior approach, corpectomy and spinal stabilization instruments have all made possible to remove the tumours of the cervicothoracic junction in a combined way. Case reports - The authors present six cases of spinal tumours where removal was done via anterior approach with partial clavicle and sternal resection. In two cases the anterior approach were combined with posterior tumour removal and fixation. Two of the cases were metastatic tumours, one lymphoma, one osteochondroma, one giant cell osteoid tumour and one malignant neurogenic tumour. The ventral approach gave a relatively wide window to explore the tumours and with the help of the operative microscope the tumour removal went fairly well. After total removal of the tumours the cervical spine were stabilized with own clavicle or iliac bone graft, titanium plate and screws. In patients with three-column involvement posterior fixation was made. The immediate recovery of the patients was well and there were no postoperative complications. Postoperative CT and MRI scans have great value in the early control after surgery as well as for the follow up of the patients. Conclusion - The anterior approach with partial clavicle and sternal resection combined with posterior approach and fixation seems to be feasible and safe method to explore and remove cervicothoracic junction pathologies.]

Clinical Neuroscience

[New minimal invasive surgical techniques in spine surgery]

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[The last decade has brought significant development in spine surgery. As in all field of surgery, introduction of the minimal invasive, atraumatic procedures characterized our activities. The number of short and long-time complications were significantly reduced and the effectiveness of operations were markedly improved by the new technical conditions, for example by the use of neuronavigation, surgical microscope, intraoperative fluoroscopy, high speed drill and the widespread of keyhole concept. The applied multislice CT imaging and the high resolution MRI enabled to improve the accuracy of the planned surgical procedures and to reduce the mortality and morbidity of operations. In our studies technical methods were investigated and new developments were established in the field of minimal invasive spine surgery. The National Institute of Neurosurgery's spinal surgical team pioneers further development and application of novel minimal invasive procedures. Applied methods of vanguard surgical procedures include split laminotomy, the “archbone” technique, the “over the top” decompression, the multilevel hemi-semi laminectomy, the supraforaminal “burr hole”, the facet joint sparing “open tunnel” techniques or parasplit minimal invasive approaches. The new innovative surgical techniques are applied in our daily routine and meet international trends by utilizing benefits of minimal invasive spinal surgery. Using our newly developed innovative techniques allow to decompress neural elements in case of spinal canal stenosis and to remove the intramedullary and extramedullary space-occupying lesions located in the spinal canal and spreading extraspinally through the neuroforamen. These techniques are specially tailored to preserve structural integrity and stability of the spinal column, and allow at the same time to minimize resection of and injury to tissues not directly involved in the pathologic processes. In our studies a classification system of spatial localization of pathological lesions and processes in spinal canal was developed by us. Using this classification system enables the surgeon to select and apply the appropriate minimal invasive technique from dorsal direction and to remove the space-occupying lesions located in the spinal canal. The minimal invasive techniques were characterized and summarized. This overview of the minimal invasive techniques can be applied and recommended in the daily routine of spine surgery. We proudly employ novel surgical techniques having been developed in our institution. These techniques are internationally recognized and applied in our practice on daily basis as well.]

Clinical Neuroscience

[REMOVAL OF INTRASPINAL SPACE-OCCUPYING LESIONS THROUGH UNILATERAL PARTIAL APPROACH, THE “HEMI-SEMI LAMINECTOMY”]

BANCZEROWSKI Péter, VAJDA János, VERES Róbert

[Objective - The conventional dorsal surgical approaches used in removal of intraspinal space-occupying lesions by unroofing the spinal canal, often result the destruction of dorsal bony structures, sacrifice the interspinosus/supraspinosus ligament complexes and stripping of the paraspinal muscles causing a pathologic biomechanical milieu may lead to spinal deformities, instability. Various less invasive techniques exist to save the integrity and to prevent the instability of the spinal column and allow removal of intraspinally located space-occupying lesions at the same time. The authors discuss the experiences with unilateral partial laminectomy approach in removal of intraspinally, mainly lateral, intra- or extradurally located pathologic lesions. Methods - The unilateral partial laminectomy, in which the laminas were preserved (hemi-semi laminectomy) was performed in 86 symptomatic patients to remove space-occupying intra- or extradurally located lesions of the cervical, thoracic and lumbar spinal canal. Symptoms were local or radicular pain, motor, sensory and vegetative disturbances. Results - Adequate surgery of the lesions located within the spinal canal was achieved in all patients using this approach. The hemi-semi laminectomy was performed at one spinal level in 68 patients, two levels in 15 and three levels in 3. The affected spine was the cervical in 16, the cervico-thoracic in 6, the thoracic in 35, the thoraco-lumbar in 10 and lumbar region in 19 cases. Histological results were as follows: 32 intradural meningeomas, 27 neurinomas, 10 ependymomas, 3 arachnoid cysts, 2 cavernomas and extradurally 4 epidural haemorrhage, 5 epidural abscesses and 3 dural vascular malformations. Conclusion - The unilateral partial laminectomy (named hemi-semi laminectomy) approach for the mainly laterally located intra- or extradural lesions, confined to one side, allow to minimize resection of and injury to tissues not directly involved in the pathologic process, while affording a safe and thorough removal of space-occupying pathologies and decompression of neural structures located in a spinal canal. Two additional advantages come from this technique in cases of misjudged level or at re-operation.]