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PubMed2006

Cervicomedullary decompression for foramen magnum stenosis in achondroplasia.

OBJECT: Achondroplasia is the most common hereditary form of dwarfism, and is characterized by short stature, macrocephaly, and a myriad of skeletal abnormalities. In the pediatric population, stenosis and compression at the level of the cervicomedullary junction commonly occurs. The goal in this study was to assess the outcomes in children with achondroplasia who underwent cervicomedullary decompression. METHODS: Forty-three pediatric patients with heterozygous achondroplasia and foramen magnum stenosis underwent 45 cervicomedullary decompressions at the authors' institution over an 11-year period. After surgical decompression, complete resolution or partial improvement in the preoperative symptoms was observed in all patients. There were no deaths in the treated patients. The surgical morbidity rate was low and usually consisted of a cerebrospinal fluid (CSF) leak in patients in whom the dura mater had been opened (either intentionally or accidentally). This problem was successfully managed in all cases with local measures (wound oversewing) or CSF diversion. CONCLUSIONS: In this review the authors demonstrate that decompression of the cervicomedullary junction in the setting of achondroplasia may be accomplished safely with significant clinical benefit and minimal morbidity.

Achondroplasia↗
PubMed2002

Bilateral decompression of lumbar spinal stenosis involving a unilateral approach with microscope and tubular retractor system.

OBJECT: The authors studied a consecutive series of patients with spinal stenosis in whom surgery was performed by a single surgeon who used a microscopic tubular retractor system (METRx-MD); patients underwent prospective evaluation involving radiography and magnetic resonance (MR) imaging. The objective was to assess the feasibility and surgery-related efficacy of performing unilateral-approach bilateral decompression and utilization of METRx-MD instrumentation in patients with spinal stenosis. METHODS: Seventeen consecutive patients with spinal stenosis underwent bilateral decompression; surgery was performed via a unilateral approach using METRx-MD instrumentation. The procedures were performed on an outpatient basis after induction of general anesthesia. Preoperative and 3-month follow-up plain radiographs with flexion-extension views were obtained. Preoperative and postoperative MR imaging was also performed. All studies were assessed by a single radiologist blinded to the clinical results. Twenty-two levels were surgically decompressed. The mean operative time was 90 minutes and the mean blood loss was 28 ml per level. Preoperatively stenosis was severe at 13 levels, moderate/severe at eight, and moderate at one. Postoperatively stenosis was absent at 13 levels, mild at seven, mild/moderate at one, and moderate at one. Preoperatively degenerative spondylolisthesis was documented in eight patients, with flexion-extension radiography revealing motion in three cases. On early (3-month) postoperative x-ray films there was no evidence of progression in any case. Grade I spondylolisthesis developed postoperatively in one patient, who remained asymptomatic. CONCLUSIONS: Minimally invasive bilateral decompression and instrumentation-assisted fusion can be successfully performed via a unilateral approach in patients with acquired spinal stenosis; the procedure can be undertaken on an outpatient basis, with reasonable operative times, minimal blood loss, and acceptable morbidity rates.

Adult↗
PubMed2002

Degenerative lumbar spondylolisthesis-induced radicular compression: nonfusion-related decompression in selected patients without hypermobility on flexion-extension radiographs.

OBJECT: The authors conducted a study to determine the results of decompressive surgery without fusion in selected patients who presented with radicular compression syndromes caused by degenerative lumbar spondylolisthesis and in whom there was no evidence of hypermobility on flexion-extension radiographs. METHODS: The medical records and radiographs obtained in 49 patients were reviewed retrospectively. Clinical status was quantified by summing self-assessed Prolo Scale scores. All 49 patients (55% female, mean age 68.7 years) presented with leg pain accompanied by lumbalgia in 85.7% of the cases. Preoperatively the median sum of Prolo Scale scores was 4. The mean preoperative degree of forward vertebral displacement was 13.5% and was located at L-4 in 67% of the cases. Osseous decompression alone was performed in 53%, and an additional discectomy at the level of displacement was undertaken in the remaining patients because of herniated discs. Major complications (deep wound infection) occurred in 2%. During a mean follow-up period of 3.73 years, 10.2% of the patients underwent instrumentation-assisted lumbar fusion when decompression alone failed to resolve symptoms. At last follow up the median overall Prolo Scale score was 8. Excellent and good results were demonstrated in 73.5% of the patients. Prolonged back pain (r = 0.381) as well as the preoperative degree of displacement (r = 0.81) and disc space height (r = 0.424) influenced outcome (p < or = 0.05); additional discectomy for simultaneous disc herniation at the displaced level did not influence outcome (p > 0.05). CONCLUSIONS: These results appear to support a less invasive approach in this subgroup of elderly patients with degenerative lumbar spondylolisthesis-induced radicular compression syndromes and without radiographically documented hypermobility. Additional discectomy for simultaneous disc herniation of the spondylolisthetic level did not adversely influence the outcome. Complication rates are minimized and fusion can eventually be performed should decompression alone fail. A prospective controlled study is required to confirm these results.

Decompression, Surgical↗
PubMed2003

Low-dose radiotherapy for the inhibition of peridural fibrosis after reexploratory nerve root decompression for postlaminectomy syndrome.

OBJECT: The authors of clinical studies have demonstrated a significant association between the presence of extensive post-lumbar discectomy peridural scar formation and the recurrence of low-back and radicular pain. Low-dose perioperative radiotherapy has been demonstrated to inhibit peridural fibrosis after laminectomy in animal models. The present study was designed to evaluate the clinical efficacy of preoperative irradiation in patients with failed-back surgery syndrome due to peridural fibrosis who underwent reexploration and nerve root decompression. METHODS: Ten patients with symptomatic post-discectomy peridural fibrosis were randomized. Half of the patients underwent 700-cGy external-beam irradiation to the operative site 24 hours prior to reexploration and decompressive treatment of their symptomatic nerve root(s) (treatment group) and the other half underwent reexploration and decompressive treatment without preoperative irradiation (control group). All patients underwent simulated irradiation so neither patient nor surgeon was aware of the patient's group. In all patients the antiadhesion product ADCON-L was placed over the affected nerve root at the time of surgery. Clinical outcome was assessed using the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Section Lumbar Disc Herniation Study Questionnaire at baseline, 6 weeks, 3 months, and 1 year follow up. Five men and five women (mean age 42 years) underwent randomization and surgery. Three patients underwent reexploration at L4-5, four at L5-S1, and three at both levels. No complication was associated with irradiation, and no new neurological deficits occurred. At 1-year follow-up examination, three irradiation-treated patients were pain free and two experienced improvement. In the control group, three patients experienced improved pain relief and two were unchanged. There was a trend toward better outcome at 1 year in the radiotherapy-treated group (p = 0.056). CONCLUSIONS: Preoperative low-dose external-beam irradiation improved clinical outcomes after reexploration and decompression of nerve roots affected by postlaminectomy peridural fibrosis causing radicular pain. The addition of preoperative irradiation may improve outcome in patients who undergo reoperation for recurrent radicular pain associated with a significant amount of peridural fibrosis, particularly now that no antiadhesion product is available for clinical use.

Adult↗
PubMed2006

Treatment of atypical trigeminal neuralgia with microvascular decompression.

AIM: To explore the methods for achieving pain relief in patients with atypical trigeminal neuralgia (TN) using microvascular decompression (MVD). STUDY DESIGN AND SETTINGS: Retrospective study of 26 patients treated during the years 2000 to 2004. MATERIALS AND METHODS: Twenty-six patients in whom vascular compression of the trigeminal nerve was identified by high definition magnetic resonance tomographic angiography (MRTA) were treated with MVD for atypical TN in our department. Clinical presentations, surgical findings and clinical outcomes were analyzed retrospectively. RESULTS: In this study, single trigeminal division was involved in only 2 patients (8%) and two or three divisions in the other 24 patients (92%). Of prime importance is the fact that in 46.2% of the patients, several conflicting vessels were found in association. Location of the conflicts around the circumference of the trigeminal root was supero-medial to the root in 53.5%, supero-lateral in 30.8% and inferior in 15.7%. MVD for atypical TN resulted in complete pain relief in 50% of the patients with complete decompression, partial pain relief in 30.8% and poor pain relief or pain recurrence in 19.2% of the patients without complete decompression postoperatively. CONCLUSIONS: Complete decompression of the entire trigeminal root plays an important role in achieving pain relief in patients with atypical TN with MVD.

Aged↗
PubMed2004

Prevention of work-related decompression illness events by detection of a cardiac right-to-left shunt.

A 44-year-old tunnel worker was studied who suffered from several unexplained decompression illness events for almost 15 years. This caisson worker was affected after standard pressure profiles that did not cause symptoms of decompression illness in his colleagues on the same shift. Transesophageal echocardiography revealed an atrial septal defect (grade II) in this otherwise healthy man. Cranial magnetic resonance imaging showed ischemic brain lesions. Among divers, patent foramen ovale, the most common cause of cardiac right-to-left shunts, was shown to increase the risk for decompression illness events by a factor of 4.5 and to double the risk of ischemic brain lesions. Hyperbaric workers with symptoms of unexplained decompression illness, even if they are only slight, should immediately be transferred to a cardiologist so that a cardiac right-to-left shunt will not be overlooked.

Adult↗
PubMed1999

Transoral decompression for craniovertebral osseous anomalies: perioperative management dilemmas.

The surgical outcome of 74 patients, who underwent transoral decompression (TOD) for ventral irreducible craniovertebral junction anomalies between January 1989 to September 1997, was studied to evaluate the perioperative complications and problems encountered. The indications for TOD included irreducible atlantoaxial dislocation (n=24), basilar invagination (n=16), and a combination of both (n=35). Following TOD, occipitocervical stabilization using Jain's technique was carried out in 50 (67.5%) and atlantoaxial fusion using Brooks' construct in 18 (24.3%) patients. The pre- and postoperative radiology was compared to assess the adequacy of decompression and stability. The major morbidity included pharyngeal wound sepsis leading to dehiscence (20.3%) and haemorrhage (4%), valopharyngeal insufficiency (8.1%), CSF leak (6.7%) and inadequate decompression (6.7%). Neurological deterioration occurred transiently in 17 (22.9%) and was sustained in 7 (9.4%) patients. The mortality in six cases was due to operative trauma, exanguination from pharyngeal wound (one each), postoperative instability and inability to be weaned off from the ventilator (two each). Of the 47 (63.5%) patients available at follow up ranging from 3 months to 2 years, 26 (55.3%) showed improvement from their preoperative status while 14 (29.8%) demonstrated stabilization of their neurological deficits. Seven (14.9%) of them deteriorated. Though TOD is logical and effective in relieving ventral compression due to craniovertebral junction anomalies, it carries the formidable risks of instability, incomplete decompression, neurological deterioration, CSF leak, infection and palatopharyngeal dysfunction.

Adolescent↗
PubMed1999

[Cerebellar hemorrhage--a rare, but serious complication in decompression disease].

Since 1978, five conferences on diving-related illness have failed to conclude that diving could lead to brain damage. We present a case history of a diver with decompression disease who also experienced brain damage. He performed a normal dive down to a depth of ten metres, when suddenly he had to go up to the surface. The patient was brought to the nearest hospital with a decompression chamber and treated according to standard procedure, yet his condition did not improve as expected. A CT scan showed bilateral, cerebellar bleeding and a secondary hydrocephalus. A CT scan one year after the accident showed a normalisation. The changes in the cerebellum could be related to decompression disease. Neurosurgery may be necessary in some cases of decompression disease.

Adult↗
PubMed2000

A trial to determine the risk of decompression sickness after a 40 feet of sea water for 200 minute no-stop air dive.

BACKGROUND: The USN93 probabilistic model of decompression sickness (DCS) predicts a DCS risk of 3.9% after a 40 ft of seawater (fsw) for 200 min no-stop air dive, although little data is available to evaluate the accuracy of this prediction. Based on an analysis of Navy Safety Center data from diving on U.S. Navy standard air decompression tables, the observed incidence of DCS for this type of dive is 0.11%. Knowing the true incidence of the dive is important for deciding whether or not to adopt proposed probability based decompression procedures for U.S. Navy diving. HYPOTHESIS: The risk of DCS after a 40 fsw for 200 min no-stop air dive is 3.9%. METHODS: We conducted a closed sequential trial to determine the DCS incidence on this dive. RESULTS: Of 30 military divers who completed 91 dives, there were 2 cases of DCS (2.2%, 95% CI: 0.27 7.7%). The study was terminated early after the second DCS case because of the presence of neurological symptoms and signs. CONCLUSIONS: This study demonstrates that the incidence of DCS in a laboratory setting is higher than observed in fleet diving. Use of the 40 fsw for 200 min schedule in a decompression computer is likely to result in DCS incidence 2.5- to 70-fold greater than that observed in U.S. Navy diving using table-based procedures.

Adult↗
PubMedDate not supplied

[Orbit decompression surgery in patients with exophthalmos caused by Graves-Basedow disease].

OBJECTIVE: To evaluate in a prospective trial two surgical technique routinely used for orbital decompression in Graves' disease ophthalmopathy. PATIENTS AND METHODS: Patients with Graves' disease exophthalmus (greater than 22 mm) that was euthyroid for at least six months after treatment were admitted to the study and randomly assigned to two groups, twenty six orbits in 17 patients were surgically decompressed with the Walsh and Ogura technique (group I) and 18 orbits in 18 patients were decompressed with Kennedy's surgical approach (group II). RESULTS: Both surgical techniques were equally effective in reducing the exophthalmus (p < 0.05). Morbility was significantly greater in terms of diplopia and infraorbital nerve lesion with Walsh and Ogura surgical approach. CONCLUSIONS: Due to reduced morbility, orbital surgical decompression with Kennedy's technique is recommended in patients with Graves' disease exofthalmus.

Adult↗
PubMed1975

Relationship between saturation exposure pressure and subsequent decompression sickness in mice.

Despite the fact that the pressure reduction is acknowledged to be the single most cogent factor in producing decompression sickness, little has been done to define accurately the allowable limits beyond 2 ATA. This study provides some theoretical guidelines for future manned dives related to this problem. There were 324 albino mice used to define the relationship between saturation exposure pressure and the safe abrupt pressure reduction. The results from both the helium-oxygen and nitrogen-oxygen exposures support the idea of a linear, depth-dependent relationship between the saturation depth and the allowable pressure reduction. Support is presented for the use of a modified decompression ratio P1/P2 (P1 equals saturation pressure and P2 equals pressure following decompression) to account for the observed incidence of decompression sickness. An attempt is made, using the existing human data to relate this empirical relationship to the operational dive setting.

Animals↗
PubMed2001

[The assessment of the risk of altitude decompression sickness during simulation of repeated (with 12 hour interval) exits into open space].

Purpose of the investigation was to assess contribution of repeated (with a 12-hr interval) decompression to the risk of altitude decompression sickness (ADS) by simulation of 6-hr extravehicular activities (EVA) of space crewmembers in altitude chamber. The protocol included "ascents" of 6 essentially healthy male subjects at the age of 24 to 51 to the altitude of 7,600 m (37 kPa) following 30-min prebreathing (elimination of nitrogen from the body by breathing pure oxygen through a mask at the ambient pressure of 73 kPa = 2,600 m). Each subject participated in 2 experimental exposures: first initial and then repeated decompression. None of 24 "ascents" produced clinical signs of ADS. Comparison of the data concerning frequency and time points of detection by ultrasonic Doppler equipment of gas bubbles (GB) in the venous bed during decompression with initial, maximal and mean values of US signal intensity failed to state a significant difference between them. Data of the investigation were confronted with anticipated length of GB dispersion in body tissues.

Adult↗
PubMed2001

[Decompressive craniectomy for massive infarction of middle cerebral artery territory].

There is continuing controversy about the benefits of decompressive craniectomy for the treatment of massive infarction of middle cerebral artery (MCA) territory. Under conservative therapy, the mortality rate for this stroke is reported to be up to 80%. So the authors have actively carried out decompressive craniectomy since 1997, and have compared the outcome with patients who were admitted before 1997 and, consequently treated with conservative therapy. Fifteen consecutive victims of massive infarction of MCA territory were studied. Seven patients (male: 1, female: 6, mean age: 79.8 years) were treated with conservative therapy, and 8 patients (male: 3, female: 5, mean age: 71.8 years) were treated with decompressive craniectomy. There were no significant differences in age and consciousness level distribution between the two groups. Mortality rate in the conservative therapy group was 85.7% against 12.5% in the surgery group (p < 0.05). Functional performance, which was evaluated by activity in daily life (ADL), was also better in the surgery group e.g. 3 patients in ADL 3, and 3 in ADL 4 (1 patient died from a non-neurological cause). Even among the patients with speech-dominant hemispheric stroke, all except one were able to communicate in some way and understand language. Even though patients in this study were elderly, decompressive craniectomy reduced mortality and improved functional performance, so it seems that this surgery should be aggressively considered for massive infarction of MCA territory.

Aged↗
PubMed2002

USAF treatment table 8: treatment for altitude decompression sickness.

INTRODUCTION: Altitude decompression sickness (DCS) has been treated with hyperbaric therapy since 1941. Treatment has essentially followed the diving DCS paradigm. Expanding space operations and higher flying, more remotely placed military aircraft have stimulated a re-examination of this paradigm. Can the oxygen and pressure-producing resources in these austere environs be reduced without sacrificing treatment efficacy? METHOD: A prospective series of 12 patients was treated with a new treatment table. USAF Treatment Table 8 (TT8) consists of 100% oxygen delivered at 2 ATA for four 30-min periods with intervening 10-min air breaks (a total oxygen dose of 2 h). Inclusion spanned 1985-1989. RESULTS: There were 10 patients who were treated 11 times for Type I altitude decompression sickness. Treatment was successful in 91%. There was one failure (a recurrence of elbow pain) requiring further therapy. Two patients were treated for Type II altitude decompression sickness. Treatment was successful in 50%. There was one failure (incomplete clearance of sensory deficits and weakness in the shoulder) requiring further therapy. CONCLUSION: Although TT8 had two failures, its successes suggest that a new protocol for the treatment of altitude decompression sickness is viable. In addition, its successes further suggest that a more extensive clinical trial is in order.

Adult↗
PubMed2001

Application of inferior major bone flap craniotomy decompression in brain injury.

OBJECTIVE: To summarize the application of inferior major bone flap craniotomy decompression in brain injury operation. METHODS: A retrospective analysis was done in 218 cases with brain injuries who were admitted to our department from January 1995 to December 1999 and treated with the inferior major bone flap craniotomy decompression. RESULTS: Of 218 cases, 121 cases (55.50%) were cured according to GOS, 39 (18.30%) were with good recovery or moderate disability, 13 (5.60) with severe deformity, 3 (1.40%) vegetative life, the rest 42 (19.20%) died after operation; no encephalocele or incarceration were found. CONCLUSIONS: The inferior major bone flap craniotomy decompression can remove hematoma timely and completely, is better than general craniotomy decompression and has a positive effect on brain injuries especially when bone flap is small.

Brain Injuries↗
PubMed2002

[Neurosurgical treatment of patients with severe thyroid-associated ophthalmopathy. Transcranial two-wall orbital decompression].

INTRODUCTION: Thyroid-associated ophthalmopathy is most often seen in patients with Graves' disease. Surgical decompression is rarely used in Denmark. We report the results of neurosurgical two-wall orbital decompression in a consecutive group of patients. MATERIAL AND METHODS: From 1997 to 2000 we used a uniform technique and a standardised follow-up of 52 orbital decompressions in 27 patients. All the patients were assessed preoperatively, and at one month and one year postoperatively. Visual acuity, proptosis (Hertel ophthalmometry), soft tissue involvement, and eye motility were recorded and graded according to a modified NOSPECS scale. RESULTS: As reduced visual acuity was present in only a few patients, it was not significantly changed during follow-up. No case with worsening was seen. Proptosis had decreased by a mean of 3.4 mm (0-9 mm) in the first month and by 3.9 mm (0-9 mm) at one year. Twenty-three patients had reduced eye motility before and 15 one month after operation. Eye motility improved in all 15 patients. Soft tissue involvement was present in 21 patients (40 eyes) before and in 10 patients (19 eyes) one month after operation and improved in all ten patients. Soft tissue involvement was further reduced one year after operation. A total of ten patients received glucocorticoid treatment before and during the operation. The corresponding figures were six at one month and four at one year. One patient had a lesion of one frontal branch of the facial nerve. No other side effects were encountered. DISCUSSION: Transcranial two-wall orbital decompression is effective in patients with thyroid-associated ophthalmopathy and complications seem rare. This surgical method is superior to other surgical approaches as regards the effect on eye motility.

Adult↗
PubMed2002

Epidemic decompression sickness: case report, literature review, and clinical commentary.

BACKGROUND: Decompression sickness (DCS) is a syndrome of symptoms caused by bubbles of inert gas. These bubbles are produced by a significant ambient pressure drop. Although cases are usually solitary there have been several episodes of DCS clusters. This paper reports an episode of epidemic decompression sickness and reviews the literature. METHODS: The case reported describes six aircrewmen with DCS following an unpressurized AC-130 flight (maximum altitude 17,000 ft). Two obvious concerns-the low altitude at which DCS was encountered and the potential for epidemic hysteria-are discussed and discounted. In addition, factors contributing to this case are recounted in depth. Moreover, the literature was examined for similar cases of epidemic decompression sickness. Four other instances were discovered. Detailed qualitative analysis of these five reports was performed. RESULTS: With this information epidemic decompression sickness is defined and classified. Two types are described-individual-based (Epi-I) and population-based (Epi-P). Epi-I is a cluster of DCS following a solitary exposure; whereas, Epi-P is a cluster of DCS following multiple exposures over time. Investigation of Epi-P follows the classical rules of outbreak investigation (time, place, person, and environment); whereas, Epi-I does not. In fact, the focus in Epi-I is almost entirely the environment. Following this outline should produce an etiology that control measures can be directed against. However, it is prudent to look beyond the etiology. Enter the Haddon Matrix, a classic public health tool that considers counter-measures before, during, and after the event. CONCLUSION: These many concepts are illustrated with the presented case. Following this template, both the expert and the novice flight surgeon have a systematic and reproducible approach to these difficult puzzles.

Adult↗
PubMed1999

[Probability models for altitude decompression sickness].

Objective. To study the probability or risk of decompression sickness in high altitude flight and to establish a probability model. Method. Survival analysis technique was used in the analysis of the information about altitude decompression sickness. Result. It was found that the risk of decompression sickness initially increases up to a certain time point, and then decreases because of denitrogenation. The hazard function may describe the characteristics of this pattern in changes of risk. The parameters of probability models for altitude decompression sickness can be estimated by using the maximum likelihood method. Conclusion. Prediction with the survival models based on the logistic distribution is good.

Aerospace Medicine↗