Osteoid osteoma of a cervical vertebral body

We report a very rare case of 5-year-old boy with osteoid osteoma of the cervical vertebral body. The patient presented with a 6-month history of neck pain with radiation into the shoulder and arm on the left side, which was relieved by ibuprofen. Neurological examination and plain radiographs of the cervical spine were normal. CT scan and bone scintigraphy, rather than MRI suggested the pathological diagnosis, which was confirmed on histological examination. The patient underwent excision of the lesion via an anterior approach with complete resolution of the pain postoperatively.

Traumatic delayed epidural hematoma

OBJECT

Traumatic delayed epidural hematoma (DEH) can be defined as a hematoma that is insignificant or not present on the initial computerized tomography (CT) scan made after trauma but subsequent CT scan shows sizeable epidural bleeding. During a 3-year period we have treated a total of 96 epidural hematomas, eight (8.3 %) of which had a delayed onset.

CASE REPORT

We present here an analysis of the eight patients with traumatic DEH which had a significant mass effect in all patients and required surgical evacuation. In three patients with mild head injury (GCS > 12) neurological deterioration indicated the necessity of repeating the CT scan and preceded the detection of DEH. In only one case of the five patients with moderate (8 < GCS < 13) and severe head injury (GCS < 9) was neurological deterioration the precursor of the DEH. All patients were immediately operated on after diagnosis. Postoperative outcome was favorable in all cases.

CONCLUSIONS

DEHs are highly unpredictable and continue to cause diagnostic difficulty. Close observation for signs of clinical deterioration and repeat CT scan are the most important factors for early detection of DEH. Early diagnosis and prompt operation offers excellent results for DEHs.

Extranodal marginal zone B-cell lymphoma most probably of MALT type appearing in CNS as parasagittal extracerebral tumor

A 63 years old male patient with systemic extranodal marginal zone lymphoma, most probably originating from mucosa associated lymphoid tissue (MALT) involving central nervous system (CNS) is presented. The usual site of origin of this type of lymphoma was not identified. The diagnosis was stated after neurosurgery according to histopathology, immunohistochemistry and additional haematologic examination. Postoperative therapy included local irradiation (30Gy) of rest tumor, combined by Rituximab-CHOP (R-CHOP) protocol, which resulted in complete remission lasting three years up to now.

[DREZ (dorsal root entry zone) surgery for the treatment of the postherpetic intercostal neuralgia]

Postherpetic intercostal neuralgia proved to be an incapacitating pain often recalcitrant to therapy. Acute pain that accompanied Herpes zoster usually subsides spontaneously but in 10% of patients the pain persists and intensifies. The incidence of postherpetic neuralgia incrises up to 50% among elder patients. We report the case of the two 42 and 48 yers old male patient who were succesfuly relieved from the chronic postherpetic intercostal neuralgia employing the DREZ surgery (Dorzal Root Entry Zone lesion). DREZ surgicall treatment of this pain should be considered when medical therapies failed in controling pain. Subjective sensory nature of the pain should play an important role in setting the indication for DREZ surgical treatment. The most favourable pain pattern for DREZ operation is the pain of intermittent rhythm, confined theritory accompanied with the phenomenon of alodinic pain that could be provoked from the pain theritory.

Cancer pain (classification and pain syndromes)

Inspite the new informations about the physiology and biochemistry of pain, it remains true that pain is only partially understood. Cancer pain is often experienced as several different types of pain, with combined somatic and neuropathic types the most frequently. If the acute cancer pain does not subside with initial therapy, patients experience pain of more constant nature, the characteristics of wich vary with the cause and the involved sites. Chronic pain related to cancer can be considered as tumor-induced pain, chemotherapy-induced pain, and radiation therapy-induced pain. Certain pain mechanisms are present in cancer patients. These include inflammation due to infection, such as local sepsis or the pain of herpes zoster, and pain due to the obstruction or occlusion of a hollow organ, such as that caused by large bowel in cancer of colon. Pain also is commonly due to destruction of tissue, such as is often seen with bony metastases. Bony metastases also produce pain because of periostal irritation, medullary pressure, and fractures. Pain may be produced by the growth of tumor in a closed area richly supplied with pain receptors (nociceptors). Examples are tumors growing within the capsule of an organ such as the pancreas. Chest pain occurring after tumor of the lung or the mediastinum due to invasion of the pleura. Certain tumors produce characteristic types of pain. For example, back pain is seen with multiple myeloma, and severe shoulder pain and arm pain is seen with Pancoast tumors.

[Cordotomy in the treatment of pain conditions]

During the time interval from January 1978 to January 2003, total of 128 chordotomy procedures have been done due to cancer's pain at the Institute of neurosurgery in Clinical Centre of Serbia. That pain has been mostly of uncontrolled intensity and it was resistant on applieed conservative treatment. Bilateral chordotomy has been performed in 6 patients only in exceptional cases when fixed paraplegia has proved; unilateral chordotomy has been performed in 122 cases. Bilateral chordotomy is much more dangerous than unilateral one because of greater posibility of appearance of motor deficits, sphincteral disturbances or subsequent formed pain. This procedure has several negative aspects. Firstly, it is an opened surgical intervention in general anesthesia and therefore, there is no communication with patient. We had a habit to perform DREZ surgery rather than chordotomy when ever it has been indicated. In 80.1% of all cases, the successfulness of surgery has been marked as excellent, in 15.2% of all cases, it has been marked as good, and in 4.7% of all cases, bad outcome has been detected. The rate of complication was 4.4%.

[Idopathic tigeminal neuralgia--radiofrequency rhizotomy of ganglion Gasseri]

Idiopathic trigeminal neuralgia (ITN), (tic dou-loureux), may be defined as a chronic painfull disorder of the sensory divisions of the trigeminal nerve, with unexplained cause and pathogenesis. The clinical features are characterized by recurrent paroxysmal lancinating pain confined to distribution of one or more branches of the nerve. Radiofrequency rhizotomy (RFR) of ganglion Gasseri is a methode of choise in treatment of ITN. We present the series of 1600 patients suffering from ITN who underwent RFR between 1984 and 2001. Ages ranged from 29 to 88 years, with a mean age of 62 years. Total pain relief immediately after a single radiofrequency lesion was achieved in 1469 (92%) of patients. After one year a recurrence of pain was present in 145 (10%). Age, sex and duration of illness were unrelated to outcome. Patients previously treated by open surgery appeared to receive less benefit from subsequent RFR. Clinical outcome correlated with the degree of sensory deficit created by RFR. Patients acquiring dense deficit demonstrated a reduced risk of recurrence: 203/1129 (18%) of patients with dense sensory loss and 75/258 (29%) of those with a partial deficit developed a recurrence by three years, whereas almost all patients (78/82) without initial sensory loss suffered a recurrence by three years. Serious complications resulting from RFR were infrequent and the most common was the permanent dysesthesia in 9 (0.6%) of patients. Our results suggest that the RFR is an well bearable and effective longterm surgical treatment for ITN, especially for older and poor-risk patients.

Microsurgical spinothalamic chordotomy in the treatment of cancer pain

PURPOSE

Advances in cancer treatment continue to lengthen survival among cancer patients. As patients live longer, the need for effective pain control has gained increased importance for improving quality of life. In patients who do not respond to all available conservative methods of therapy for cancer pain, surgical methods have been applied; one of them is the open high thoracic spinothalamic chordotomy.

PATIENTS AND METHODS

We present a group of 86 patients suffering from nociceptive cancer pain, caused by compression of lumbosacral plexus. All patients were treated by microsurgical open high thoracic spinothalamic chordotomy. These patients did not respond to any available conservative treatment.

RESULTS

Immediately after surgery 68 (79%) patients had total pain relief. Of the remaining 18 (21%) patients, significant pain relief was achieved in 9 (10%), while in the remaining 9 patients this procedure had no effect. After a 6-month follow-up, total pain relief remained in 62 (72%) and significant pain relief in 10 (17%) of the patients. From 62 of patients with well-defined unilateral pain treated by "moderately deep" chordotomy, total pain relief was achieved in 53 (85%), lasting for 6 months in 49 (79%) of them.

CONCLUSION

These results show that microsurgical chordotomy can achieve total control of intractable cancer pain in the majority (79%) of patients, especially in those with well-defined unilateral pain (85%), indicating the usefullness of this surgical approach in the treatment of nociceptive cancer pain.

[Biomechanical characteristics of spinal cord tissue--basis for the development of modifications of the DREZ (dorsal root entry zone) operation]

Mechanical properties of the spinal cord tissue--biological basis for the development of the modality of the DREZ surgery lesioning technique Succesful treatment of the chronic neurogenic pain of spinal cord and cauda equina injury origin remains a significant management problem. The mechanism of this pain phenomenon has been shown to be related to neurochemical changes that lead to the state of hypereactivity of the second order dorsal horn neurons. The DREZ surgery (Dorsal Root Entry Zone lesion), designed to destroy anatomy structures involved in pain generating thus interrupting the neurogenic pain mechanism, as a causative procedure in treating this chronic pain, has been performed by using different technical modalities: Radiofrequency (RF) coagulation technic, Laser, Ultrasound and Microsurgical DREZotomy technic. The purpose of the study was to assess the possibility for the establishment of the lesioning technic based on the natural difference in the mechanical properties between the white and gray cord substance. We experimentally deteminated mechanical properties of the human cadaveric cord white versus gray tissue for the purpose of testing possibility of selective suction of the dorsal horn gray substance as a DREZ lesioning procedure. Based on the fact of the difference in tissue elasticity between white and gray cord substance we established a new and simple DREZ surgical lesioning technique that was tested on cadaver cord. For the purpose of testing and comparing the size and shape of the DREZ lesion axchieved the DREZ surgery has been performed on cadaver cord by employing selective dorsal horn suction as a lesioning method. After the procedure cadaver cord underwent histological fixation and analysis of the DREZ lesions achieved. Our result revealed that the white cord substance with longitudinal fiber structure had four time higher dynamical viscosity than gray substance of local neuronal network structure (150 PaS versus 37.5 PaS) that provided possibility for the safe and selective suction of the gray substance of the dorsal horn. Technic includes incision of the dorsolateral sulcus according to Sindous Microsurgical DREZotomy technic than suction under visual control of the dorsal horn gray matter using succer adopted from the lumbar puncture nidle. Operative experimental testing and hystological analysis confirmed expected size and shape of the DREZ lesion performed by dorsal horn suction as DREZ lesioning technique. The utility, selectivity and safety of this technic has been provided by the natural mechanical properties of the cord tissue itself. Application of the Dorsal horn suction as a DREZ lesioning in humans confirmed this technic as a safe and reliable DREZ lesioning method.

[Indications for surgical treatment of pain and types of operations]

During the period from 1978 to 2003 in Institut for neurosurgery CCS and Neurosurgical hospital of MA in Belgrade, 3057 patients with pain syndroms in different localisations were operated. Before operation all conservative methods were exhausted. We made 248 microvacular decompressions in fossa cranii posterior, 1600 radiophrequent lessions of ggl. Gasseri and 64 avulsions of distal trigeminal branches in patients with trigeminal and glossopharingeal neuralgia, 128 chordotomies in patients with neurogenic and cancer pain, 62 DREZ operations in patients with paraplegia, cancer pain and postherpetic intercostal neuralgia. More than 900 patients have been operated because of neuropathic pain and trauma of peripheral nerves, and 48 patients were operated due to Phantomzs pain. We compared results of two alternative methods in treatment of trigeminal neuralgia (radiophrequent lesion of ggl. Gasseri and microvascular decompression in posterior fossa).

Cancer pain: Neurosurgical management

The management of cancer pain represents a difficult diagnostic and therapeutic problem for the clinician. In a multidisciplinary approach to the management of cancer pain, neurosurgical methods are an essential part of the therapy. Frequently, patients with advanced cancer suffer from an increasing pain, requesting ever higher dosage of narcotics, and finally seeming to respond only to high dosage of intravenous narcotics. Gradually, the opioids produce less satisfactory analgetics effects an more serious side manifestations. These patients can be considered for surgical management of pain. Historically, surgery for cancer pain began with destructive procedures (neurectomy, rhizotomy, sympathectomy), often referred to as ablative. In past two decades, with the help of the current knowledge of cancer pain mechanisms and some of the technological developments, such as microsurgical and stereotactic techniques, computerized tomography and magnetic resonance imaging, the majority of ablative procedures have been replaced by new methods. Among them a few are selectively and minimally ablative (microsurgical spinothalamic cordotomy, dorsal root entry zone operation, limited midline myelotomy) and the others ones are neuroaugumentative operations ( deep brain structures and spinal cord stimulation, drugdelivery systems).