Neurosurg Focus
-
Multicenter Study Clinical Trial
Treatment of lumbar spinal stenosis with a total posterior arthroplasty prosthesis: implant description, surgical technique, and a prospective report on 29 patients.
Total disc replacement is an alternative to lumbar fusion, but patients with spinal stenosis, spondylolisthesis, and facet arthropathy are often excluded from this procedure because increased adjacent-segment motion can exacerbate dorsal spondylotic changes. In such cases of degenerative spondylolisthesis with stenosis, decompression and fusion remain the gold standard of treatment. To avoid attendant loss of motion at the treated segment, the TOPS system is a novel total posterior arthroplasty prosthesis that allows for an alternative dynamic, multiaxial, three-column stabilization and motion preservation. The purpose of this study is to report preliminary surgical data and clinical outcomes in patients treated with the TOPS lumbar total posterior arthroplasty system. ⋯ The TOPS total posterior arthroplasty system represents a novel, dynamic, posterior arthroplasty device that provides multiaxial stability in flexion, extension, rotation, and lateral bending after total facetectomy and neural decompression. The surgical data indicate that it can be safely applied via a traditional approach with low surgical morbidity and excellent 1-year functional and radiographic outcomes in patients with degenerative spondylolisthesis accompanied by stenosis and back pain.
-
Brain edema is a common pathophysiological process seen in many neurosurgical conditions. It can be localized in relation to focal lesions or generalized in diffuse types of brain injury. In addition to local adverse effects occurring at a cellular level, brain edema is associated with raised intracranial pressure (ICP), and both phenomena contribute to poor outcome in patients. ⋯ In these patients, opening the skull (decompressive craniectomy) to reduce ICP is a potential option. In this review the authors discuss the role of decompressive craniectomy as a surgical option in patients with brain edema in the context of a variety of pathological entities. They also address the current evidence for the technique (predominantly observational series) and the ongoing randomized studies of decompressive craniectomy in TBI and ischemic stroke.
-
Stereotactic radiosurgery (SRS) with the Gamma Knife and linear accelerator has revolutionized neurosurgery over the past 20 years. The most common indications for radiosurgery today are tumors and arteriovenous malformations of the brain. Functional indications such as treatment of movement disorders or intractable pain only contribute a small percentage of treated patients. ⋯ Radiosurgical ventrolateral thalamotomy for the treatment of tremor in patients with Parkinson disease or multiple sclerosis, as well as in the treatment of essential tremor, may be indicated for a select group of patients with advanced age, significant medical conditions that preclude treatment with open surgery, or patients who must receive anticoagulation therapy. A promising new application of SRS is high-dose radiosurgery delivered to the pituitary stalk. This treatment has already been successfully performed in several centers around the world to treat severe pain in patients with end-stage cancer.
-
Review Historical Article
Hippocrates, Galen, and the uses of trepanation in the ancient classical world.
Trepanation is the process by which a hole is drilled into the skull, exposing the intracranial contents for either medical or mystical purposes. It represents one of the oldest surgical procedures, and its practice was widespread in many ancient cultures and several parts of the world. ⋯ The purpose of this paper is to examine Hippocrates' and Galen's written accounts of the technique and use of trepanation in the ancient Greek and Roman world. Examination of those records reveals the ancient knowledge of neurological anatomy, physiology, and therapeutics, and illustrates the state and evolution of neurosurgery in the classical world.
-
Radiosurgery has proven useful in the treatment of small arteriovenous malformations (AVMs) of the brain. However, the volume of healthy tissue irradiated around large lesions is rather significant, necessitating reduced radiation doses to avoid complications. As a consequence, this can produce poorer obliteration rates. ⋯ Investigators dispensing >or= 7 Gy per fraction minimum doses have achieved occlusion with an acceptable number of complications in 53-70% of patients. The extended latency period between treatment and occlusion, about 5 years for emerging techniques (such as salvage, staged volume, and hypofractionated radiotherapy), exposes the patient to the risk of hemorrhage during that period. Nevertheless, improvements in dose planning and target delineation will continue to improve the prognosis in patients harboring inoperable AVMs.