Subsidence and its effect on the anterior plate stabilization in the course of cervical spondylodesis. Part I: definition and review of literature

A definition of subsidence in terms of spinal biomechanics is presented in the paper. Subsidence is defined as sinking of a body with a higher elasticity modulus (e.g. graft, cage, spacer) in a body characterized by a lower elasticity modulus (e.g. vertebral body), resulting in 3D changes of the spinal geometry. Magnitude of subsidence is directly proportional to the load pressure and to the difference between the elasticity modules, but inversely proportional to the area of the graft-bed interface. Both biological and mechanical qualities of the graft-bed interface are important for the subsidence process. Any excessive subsidence decreases the interbody space and produces both local and general kyphotization of the spine. This may cause destabilization of the screw-plate and/or screw-bone interfaces (e.g. pulling-out, altered angulation or breakage of the screws). A method is proposed of radiological estimating the absolute magnitude of subsidence, based on the real known length of the implanted stabilizer (e.g. plate). Clinical examples of an excessive subsidence and its impact on the stabilizing plate system are presented. Subsidence is inherent in the interbody fusion process. Endplate preservation and a dynamic modification of cervical plates may enables us to control subsidence and reduce the number of complications.     

Diagnosis and treatment of carcinoid meningitis: a challenge to the neurologist and oncologist

BACKGROUND: Two clinical types of leptomeningeal metastases from solid tumors are observed: local and disseminated. The former (meningeal carcinomatosis) consists in nodular infiltration of leptomeninges, while the latter (carcinomatous meningitis)--in tumor cells free floating in the cerebrospinal fluid and adhering as a monolayer to the surface of neural structures. Despite the same etiology, the two types of metastasis differ in their clinical manifestation and prognosis. Meningeal carcinomatosis is more frequently diagnosed nowadays due to advances in neuroimaging techniques and the long survival of breast cancer patients. Patients with local, nodular infiltration of leptomeninges may survive many years without symptoms of the disease. On the other hand, carcinomatous meningitis, with its usually violent course and short survival, has become a major problem for oncologists and neurologists because of limited efficacy and considerable toxicity of the treatment. AIMS: The purpose of this article is to review the current knowledge about carcinomatous meningitis in breast cancer patients, taking into account pathophysiology, clinical symptoms, diagnosis, treatment and prognosis. The second aim was to present the authors' experience with the treatment of breast cancer patients suffering from carcinomatous meningitis. MATERIAL AND METHODS: 37 patients with breast cancer and carcinomatous meningitis were treated in the Oncology Center, Warsaw, in the years 2000-2002. Their mean age was 51. The diagnosis was based on results of neurological examination, MRI scan, and the presence of neoplastic cells in the cerebrospinal fluid. In a majority of cases combined treatment was applied, including intrathecal administration of cytostatics, intravenous systemic chemotherapy and radiotherapy. RESULTS: The observation period ranged from 2 to 33 months. A response to the treatment was achieved in 76% of the patients. Their median overall survival was 19 weeks, mean 18 weeks. Seven patients (19%) survived for over 6 months. CONCLUSIONS: The ever-growing incidence of carcinomatous meningitis in the course of breast cancer has become a serious clinical problem for neurologists and oncologists. Treatment results are disappointing, although the combined modality treatment appears to be the best option. New pharmacological approaches to the treatment of meningeal malignancy are required to improve the outcome of patients with carcinomatous meningitis.     

Post-traumatic unilateral atlanto-axial rotatory subluxation in an adult

This retrospective single-patient case report deals with a rare form of spinal trauma, i.e. atlantoaxial rotatory subluxation. The authors present a review of the literature including a classification of rotatory atlantoaxial subluxation types proposed by Fielding, and describe their own experience with treatment of this condition. A case is reported of a 29-year-old woman with a history of head contusion in a car accident. Immediately after the trauma she had the following symptoms: torticollis and neck pain with decreased cervical motion. Atlantoaxial rotatory subluxation of the right C1-C2 articulation was diagnosed by plain radiographs and CT. The patient was treated surgically by an open reduction, unilateral screw fixation of the right CI-C2 articulation (according to Magerl) and posterior C1-C2 wiring with graft. The normal atlantoaxial relation was restored with disappearance of torticollis. At follow-up certain limitation of neck movements due to C1-C2 stabilization persisted. No complications were noted. The patient remains neurologically intact and has radiographic documentation of fusion.     

Advances in the research on immunopathogenesis of myasthenia gravis

Microscopic structure and immunologic function of the thymus gland are outlined, with an emphasis on its role in the process of T and B lymphocytes maturation. Other types of thymic cells are also described, including epithelial and myoid cells that presumably have a central role in initiation of an autoimmunologic process leading to myasthenic symptoms development. A detailed account is presented of issues concerning pathophysiology of myasthenia, the structure of nicotinic acetylcholine receptor (AchR) at neuromuscular junctions, and mechanisms underlying its destruction by autoantibodies. The role of T and B lymphocytes, of various cytokine types, of autoantibodies to various striated muscle antigens, as well as a possible role of genetic and bacterial factors in the development of myasthenia gravis are discussed. In conclusion it is stressed that since recent research findings go beyond the classic theory of myasthenia, a new consistent theory of the disease immunopathogenesis must be created in the future to place all the newly discovered phenomena in a logical conceptual structure.     

Transsphenoidal surgery of intrasellar and perichiasmatic tumors--personal experience

Microsurgical transsphenoidal approach has been for decades an established standard surgical treatment of pituitary adenomas. Actually it offers a safe and rapid midline access to the sellar region with a minimal risk of injury to vascular vessels, the optic chiasm or nerves and the brain. Major limitations of this approach are due to the narrow and deep operating field, with the related possible complications of the pituitary insufficiency and the cerebrospinal fluid rhinorrhea. In this paper the authors present their own experience with transsphenoidal surgery they performed in over 1500 cases during the past 28 years. The history and evolution of the microsurgery are described, including the operative technique, indications and counter-indications, as well as relative advantages and disadvantages of the transsphenoidal approach. Moreover, current modifications of the neurosurgical technique (extended transsphenoidal approaches) and their application in the treatment of non-glandular perichiasmatic tumors are outlined and discussed.     

Intrathecal baclofen in severe spasticity due to multiple sclerosis

Intrathecal administration of baclofen via programmable pump is a highly effective treatment method in severe spasticity resistant to oral medications. The authors describe a case of severe spasticity with tetraplegia and painful (> 10 a day) muscle spasms in the upper and lower limbs and paraspinal muscles, in a patient with clinically definite diagnosis of multiple sclerosis (MS). The 34-year-old female patient with a 15-year history of MS, suffering from lower limb spasticity with pes equinovarus since 1995, was treated with very good results with botulinum toxin injections of calf muscles (14 sessions of Dysport 1500iu till 2002). In the early 2002 she developed tetraplegia with severe, generalized and intractable spasticity. After 4 months of ineffective polytherapy (with high doses of oral baclofen, tizanidine, gabapentine, clonidine, diazepam) and the patient's enormous sufferings (she could neither sit up nor voluntarily change her position in bed), a programmable baclofen pump (Medtronic) was implanted. As soon as a few days after the surgery she could stand, sit and move voluntarily, her painful spasms disappeared, and her bladder catheter was removed. At a 6-month follow-up the effect was stable--she was able to walk a long distance outdoors with the aid of a crutch. The daily dose of the drug is 500 micrograms. No side effects of complications were noted.     

Own experience in surgical treatment of the pineal region and midbrain tumors via the infratentorial approach

Nine cases of tumours located in the pineal and midbrain region in adults operated on between November 1998 and July 2002 in Dept. of Neurosurgery, Central Military Hospital in Warsaw are reported. The patients (2 men and 7 women) were aged from 27 and 69 years (mean age 43.6 years). Their main initial symptoms were caused by hydrocephalus. The histopathological examination revealed anaplastic pinealoma in 2 cases, and pineocytoma, pineal cyst, mesencephalic glial cyst, protoplasmatic astrocytoma, epidermoid cyst, unclear glial scar, and papillary ependymoma in single cases. Five patients had been treated, usually elsewhere, with shunt implantation prior to the surgery. Occipito-suboccipital osteoplastic craniotomy was performed in each case and tumours were totally removed microsurgically via the infratentorial epicerebellar approach. In one case a part of the glial periaqueductal tumour was resected additionally via the fourth ventricle and aqueduct in one stage. Postoperative haematomas in the third and fourth ventricle were found in 2 cases. Main complaints after the surgery included transient diplopia. All the patients improved significantly and resumed their previous life activities. Follow-up ranged from 3 to 44 months. Three patients with pineal tumours and one with a small postoperative ependymoma recurrence were irradiated after the surgery. One patient had been irradiated prior to surgery. Very good results of the surgical treatment of tumours in this area suggest that such patients should be referred earlier to one stage surgical management, as the procedure is easier to perform and shunt implantation may be avoided.     

Tuberculosis of the central nervous system: case reports

Tuberculosis of the central nervous system possess a serious clinical and radiological problem, since early treatment of this condition is crucial for the patient's life, and tuberculous process in the CNS may mimic many other pathologies. In this paper three cases of tuberculous process difficult to diagnose are presented. In all the cases early treatment could be started due to MRI findings suggesting tuberculous etiology. The authors emphasize the importance of presumptive radiological diagnosis in reducing the morbidity and mortality rates due to CNS tuberculosis.     

Perception of emotions from faces and voices following unilateral brain damage

The importance of the right hemisphere in emotion perception in general has been well documented but its precise role is disputed. We compared the performance of 30 right hemisphere damaged (RHD) patients, 30 left hemisphere damaged (LHD) patients, and 50 healthy controls on both facial and vocal affect perception tasks of specific emotions. Brain damaged subjects had a single episode cerebrovascular accident localised to one hemisphere. The results showed that right hemisphere patients were markedly impaired relative to left hemisphere and healthy controls on test performance: labelling and recognition of facial expressions and recognition of emotions conveyed by prosody. This pertained at the level of individual basic emotions, positive versus negative, and emotional expressions in general. The impairment remained highly significant despite covarying for the group's poorer accuracy on a neutral facial perception test and identification of neutral vocal expressions. The LHD group were only impaired relative to controls on facial emotion tasks when their performance was summed over all the emotion categories and before age and other cognitive factors were taken into account. However, on the prosody test the LHD patients showed significant impairment, performing mid-way between the right hemisphere patients and healthy comparison group. Recognition of positive emotional expressions was better than negative in all subjects, and was not relatively poorer in the LHD patients. Recognition of individual emotions in one modality correlated weakly with recognition in another, in all three groups. These data confirm the primacy of the right hemisphere in processing all emotional expressions across modalities--both positive and negative--but suggest that left hemisphere emotion processing is modality specific. It is possible that the left hemisphere has a particular role in the perception of emotion conveyed through meaningful speech.     

The frequency of diagnosis of catatonic schizophrenia in hospitals in Lubliniec (1894-1932, 1934-1936, 1970-1999) and Boleslawiec (1958-1999)

AIM: The analysis of the data from the psychiatric hospitals in Lubliniec (1894-1932, 1934-1936, 1970-1999) and Boles?awiec (1958-1999) proved a decrease in frequency of diagnosis of catatonic schizophrenia, what could testify to a decrease in morbidity with this form of schizophrenia. METHOD AND RESULTS: Basing on the facts from scientific literature there was ascertained that the decrease in frequency of diagnosis of catatonic schizophrenia is connected with following causes: firstly, with the changes in nozology, secondly, with the introduction of a new form of therapy and finally, with the fact that here psychological and sociological factors exist which eliminate catatonia as the most expressive form of schizophrenia.