Biomedical subjects
Publications and source records attributed to A P Fabrizi.
Annulotomy is a mandatory step to perform intradiscal decompression to resolve a disco radicular conflict. However, this manoeuvre can lead to post surgical complications such as vertebral instability and back pain. Coblation assisted microdiscectomy (CAM procedure) allows a quoted removal of disc without anulus damage.
The authors present a series of 47 patients with craniopharyngiomas treated by stereotaxy in the past 15 years. There was no mortality nor immediate postoperative morbidity in the treatment of the cystic portion of the neoplasm. Intracavitary colloidal yttrium (90Y) was extremely effective in obtaining long-lasting disappearance of craniopharyngioma cysts. In children, yttrium worsened panhypopituitarism, while it was well tolerated by teenagers and adults. Craniopharyngiomas are often mixed (solid-cystic) and the majority of cases have a predominant cystic portion, where stereotaxy is a valid alternative to open surgery, which presents a high morbidity and mortality.
Intracranial germinomas arising primarily within the sella turcica are extremely rare. Preoperative diagnosis is difficult to establish even with sophisticated procedures. Diabetes insipidus is the main clinical manifestation. The authors report a case of an apparently primary intrasellar germinoma causing subclinical pituitary apoplexy in a 12-year-old boy. The transsphenoidal approach and appropriate radiotherapeutic management were employed with a good outcome.
A case of ulnar neuropathy at the elbow produced by spontaneous intraneural hemorrhage in a patient with acquired immunodeficiency syndrome and thrombocytopenia is reported. Intraneural hemorrhage in patients with bleeding disorders occurs infrequently. It consists of acute intrafascicular bleeding, presumably producing very high elevations of endoneurial fluid pressure. The clinical features and treatment of this condition are considered, the pertinent literature is reviewed, and the involved pathophysiological mechanisms are discussed.
A report is given on indications and results of treatment of chronic cancer pain using stereotactic mesencephalic tractotomy (SMT), based on own experiences in 202 patients. Percutaneous cervical cordotomy for upper body pain syndromes has been abandoned and replaced by SMT. Operative mortality of SMT was less than 0.5%, and also its morbidity was low and usually transitory. Bilateral procedures may be performed with an interval of at least seven days. Early recurrences within one month (15%) are due to insufficient coagulation. Late pain recurrence occurred in 4% and may be due to either nervous system regeneration (sprouting) or transmission of pain by alternate secondary pathways.
The authors report on indications and results of percutaneous surgical treatment of trigeminal neuralgia based on own experiences in 1124 cases. In 912 cases percutaneous thermorhizotomy and in 212 cases percutaneous microcompression have been used. As a conclusion the following considerations have been stressed: I) In both methods slight hypaesthesia appears to obtain good pain relief; II) Percutaneous thermorhizotomy is indicated in third division neuralgias; III) Percutaneous microcompression is indicated for first and second division neuralgias only when the trigeminal cistern is not abnormally dilated; IV) Undesirable side-effects after either thermorhizotomy and microcompression are similar and transitory in most cases; V) Pain recurrence for both procedures are comparable and range at about 25%.
One hundred and twenty patients with soft lateral disc herniation underwent surgery by anterior microsurgical discectomy and routine ablation of the posterior longitudinal ligament between 1976 and 1986. The study excluded patients with hard discs and soft disc extrusion with medullary symptoms. In our series 76.6% of patients were men. In 64% of the patients no causative factor was found. All of the patients presented with cervicobrachialgia; 53% also had a motor deficit. In 91.7% a single disc was involved. The last 40 cases were evaluated by computed tomography alone. In 51.5% an extruded disc was found. No permanent postoperative complication was encountered. All patients returned to their previous activities. Fifty patients underwent follow-up radiological evaluation at 1 and 5 years after the intervention and vertebral fusion was observed in 70% of these.
Intraaxial brain stem tumours are rarely treated by open surgical technique. In Bologna and Marseille, 23 and 10 stereotactic biopsies respectively were performed in patients with brain stem mass lesions. The mortality due to biopsy was 3% (1 pat.); while the morbidity was temporary in 6 cases (18%) and permanent in one patient (3%). The approach to the brain stem was via a frontal burr hole. 7 times, after biopsy and histological diagnosis, radioisotope implant of the neoplasm was performed with 125I (iodine). From the histological diagnoses of the lesions the following was found: only 40% of the young patients had highly malignant tumours; 83% of the adults had neoplasms (not all of the malignant type), while 17% of the verified lesions were non-neoplastic. Since a diagnosis of the lesion nature is impossible with current neuroradiological means, the authors noting a variety of masses found in their experience, emphasize the importance of stereotactic biopsy, as a scarcely invasive method to give a precise diagnosis and a possible treatment.
A series of 100 patients underwent surgical treatment for chronic subdural hematomas between 1979 and 1987. The procedure consisted of craniectomy with a 30-mm trephine, irrigation and drainage of the hematoma, laceration of the outer and inner membranes, and lumbar intrathecal injection of Ringer's lactate solution for immediate cerebral reexpansion (average injection, 130 ml). This technique gave the following results: 2% mortality, 2% moderate morbidity, and 96% recovery. The recovery of the patients was rapid, and good outcome was achieved in Grade 3 and Grade 4 cases (Markwalder's classification).
A series is presented of 106 patients with extrapyramidal syndromes treated by stereotaxy. The importance of preoperative screening to assure favorable results is stressed. Surgical contraindications are elderly patients with dementia and akinesia. Axial dystonia and spasmodic torticollis respond poorly to stereotaxy; and bilateral interventions should be avoided.
Over a period of 5 years, 34 pediatric patients underwent stereotactic surgery for deep-seated brain lesions: 32 patients proved to have a brain tumor, and in 2 cases the lesion was not tumoral; 15 patients with low-grade astrocytomas were treated with 125I interstitial radiotherapy. The importance of stereotactic surgery is emphasized because of its relative safeness, diagnostic reliability, and the possibility of eventual brachytherapy.
The authors report their series of 45 patients harboring inoperable, low-grade cerebral neoplasms, treated in the past 6 years with 125I stereotactic brachytherapy. The majority of these tumors were grade I and II astrocytomas and oligodendrogliomas (82.2%). A 2.6- to 6-year follow-up shows good results in 65.6% with reduction or disappearance of the lesions on CT images and good social reentry. Nine patients (23.7%) died prior to follow-up. Young patients (less than 40 years) responded well to interstitial radiotherapy, while patients over 40 with the same histological findings of low-grade tumors responded poorly to this type of treatment. Diffuse infiltrating cortico-subcortical tumors, optochiasmatic gliomas, hypothalamic and lower brainstem neoplasms do not respond satisfactorily to 125I radioisotope implantations.
Two neurosurgical centers, Bologna (Italy) and Freiburg (FRG), have compared results obtained with stereotactic mesencephalotomy (SM; Bologna) and multiple thalamotomies (MT; Freiburg) in the surgical treatment of chronic cancer pain syndromes. In total, 161 patients were operated, 109 in Bologna and 52 in Freiburg. In SM the lesions were single and centered on the spinothalamic tract at the mesencephalic level, while in MT the lesions were multiple in the thalamic nuclei (ventrocaudal parvocellular nucleus, nucleus limitans, lamella medialis, centromedian nuclei). The following results emerged after 2-7 months' follow-up: (1) in an antalgic sense, SM was much more beneficial, with 91 patients (83.5%) pain-free after the operation versus 27 patients (51.9%) who had only an attenuation of the pain syndrome after MT; (2) SM, compared to MT, is burdened by mortality and a higher morbidity [2 deaths (1.8%) vs. 0; 3 anesthesia dolorosa and 8 severe gaze palsies (10.1%) vs. only 1 case of permanent aphasia (1.9%)].
Thalamic masses are generally considered inoperable; little is known of the precise nature of these lesions. Stereotactic biopsy was performed in 44 patients, with no mortality and low morbidity (only 1 case of transitory hemiparesis). The stereotactic biopsy (minimum 5 specimens taken along the major axis of the lesion) showed that the majority of the young patients (less than 40 years) had low-grade glial neoplasms (grade I-II astrocytomas or oligodendrogliomas), while in older patients highly malignant tumors prevailed. Beside the neoplasms in the children and adults, we found granulomas, abscesses, infarcts, hemorrhages and glioses. Present neuroradiological methods cannot establish a final correct diagnosis in thalamic lesions, so stereotactic biopsy is recommended. A follow-up of 1-6 years is presented for 7 patients who underwent stereotactic 125I brachytherapy.
The authors report their results of 37 patients with low malignancy brain tumors seated in deep or highly functional areas not amenable to traditional surgery, nor to conventional radiochemotherapy. In the past 5 years these patients were treated by means of stereotactic interstitial radiotherapy. The isotope employed in all cases was 125I. Stereotactic radioisotope implants were always preceded by multiple stereotactic biopsies affording precise histological diagnoses. A 6-month to 5-year follow-up shows a survival rate of 72.6% (29 patients), and of these patients, 80.9% (26 out of 29) had complete social reentry.
A case of solitary schwannoma and one of solitary neurofibroma originating from the spinal accessory nerve in the posterior triangle of the neck are described. Location of such neoplasms in this region is exceptional. The authors emphasize the importance of accurately enucleating the mass; when it is impossible to preserve the continuity of the neural pathway, nerve repair should be considered.
The authors report their experience of 53 patients with low grade malignancy cerebral neoplasms treated by means of stereotactic 125-I permanent interstitial radiotherapy. The method has been employed from 1981 to date. The authors confirm the validity of the technique in this brief report, and stress the greater efficacy of this treatment in young patients (less than 40 y/o) than in adults.