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PubMedDate not supplied

Ancillary procedures in microscopic endonasal orbital decompression for thyroid-associated ophthalmopathy.

In 35 patients with thyroid-associated orbitopathy, nonresponsive to conservative treatment, an endonasal microscopic approach with bimural osteotomy was performed for decompression in two ways. While in group A the periorbita was resected, and fat septa were cut, in group B periorbital strips were left, and fat septa were respected. In accordance with other authors, resection of the periorbital and cutting fat septa will improve vision and proptosis, but in up to 30% of the patients de novo diplopia occurs. Our data favor the assumption that a more conservative endonasal microscopic decompression of the orbita leaving periorbital strips and fat septa achieves similar good results for reduction of proptosis and visual gain but creates less often de novo diplopia in primary gaze. Based on our experience, rehabilitation for thyroid-associated arbitopathy comprises as a first step orbital endonasal decompression with cooperation of the ophthalmologist, then if necessary as a second step strabismus surgery, and thirdly eyelid repair for scleral show.

Adult↗
PubMed2002

Abdominal compartment syndrome in severe acute pancreatitis: an indication for a decompressing laparotomy?

BACKGROUND: The currently prevailing paradigm calls for non-operative management of severe acute pancreatitis for as long as there is no evidence of infection. Our purpose in presenting this anecdotal experience is to propose that there is a subset of patients who may need a laparotomy in the absence of infection in order to decompress a clinically significant abdominal compartment syndrome (ACS), which is associated with the acute pancreatitis. METHODS: We present our recent experience with three patients suffering from severe acute pancreatitis. The three developed intra-abdominal hypertension (IAHT) and clinical ACS, which necessitated abdominal decompression and a laparostomy. One patient survived. CONCLUSIONS: The notion that patients with severe acute pancreatitis may develop ACS, which necessitate emergency abdominal decompression, has been ignored by current surgical literature. Only increased awareness to the syndrome of IAHT-ACS in acute pancreatitis and transvesical measurement of intra-abdominal pressure will reveal its prevalence and significance.

Acute Disease↗
PubMed2003

Recurrence of symptoms after Chiari decompression and duraplasty with nonautologous graft material.

Nonautologous material is commonly used for dural grafting. Although good results have been reported with the use of some of these materials in cranial surgery, there is a paucity of information regarding their use in craniocervical decompressive surgery. We report three cases of patients with Chiari malformation type I who experienced recurrent or new-onset Chiari symptoms after surgical decompression and duraplasty with bovine pericardium, Gore-Tex or cadaveric dura. We review the use of these materials and propose possible mechanisms by which a reaction to a nonautologous graft could cause recurrent Chiari symptoms. The preferential use of autologous material for dural grafts during posterior fossa decompressive surgery should prevent this cause of symptom recurrence.

Adult↗
PubMed1999

Decompressive craniectomy, reperfusion, or a combination for early treatment of acute "malignant" cerebral hemispheric stroke in rats? Potential mechanisms studied by MRI.

BACKGROUND AND PURPOSE: Both early reperfusion and decompressive craniectomy have proved beneficial in the treatment of large space-occupying "malignant" hemispheric stroke. The aim of this study was to directly compare the benefit of reperfusion with that of craniectomy and to study the effects of combined treatment in a rat model of focal cerebral ischemia. METHODS: Cerebral ischemia was introduced in 28 rats. Four groups were investigated: (1) no treatment, (2) decompressive craniectomy, (3) reperfusion, and (4) reperfusion and craniectomy as treatment at 1 hour after middle cerebral artery occlusion. Perfusion- and diffusion-weighted MRI were performed serially from 0.5 to 6 hours after middle cerebral artery occlusion. RESULTS: The 6-hour DWI-derived hemispheric lesion volumes in the reperfusion group (10.2+/-3.9%), the craniectomy group (23.0+/-6.4%), and the combination group (21.8+/-12.4) were significantly smaller than that in the control group (44.1+/-5.4%) (P<0.05). Reperfusion, craniectomy, and combined treatment led to higher perfusion in the cortex compared with the control group, whereas only reperfused animals achieved significantly higher perfusion in the basal ganglia. In 5 animals, combined reperfusion and decompressive craniectomy resulted in an early contrast media enhancement. CONCLUSIONS: Early reperfusion and craniectomy were shown to be effective in decreasing infarction volume by improving cerebral perfusion. Reperfusion remains the best therapy in malignant hemispheric stroke. Combined treatment yields no additional benefit compared with single treatment, probably because of early blood-brain barrier breakdown.

Acute Disease↗
PubMed1999

Decreases in blood pressure and sympathetic nerve activity by microvascular decompression of the rostral ventrolateral medulla in essential hypertension.

BACKGROUND: Neurovascular compression of the rostral ventrolateral medulla, a major center regulating sympathetic nerve activity, may be causally related to essential hypertension. Microvascular decompression of the rostral ventrolateral medulla decreases elevated blood pressure. CASE DESCRIPTION: A 47-year-old male essential hypertension patient with hemifacial nerve spasms exhibited neurovascular compression of the rostral ventrolateral medulla and facial nerve. Microvascular decompression of the rostral ventrolateral medulla successfully reduced blood pressure and plasma and urine norepinephrine levels, low-frequency to high-frequency ratio obtained by power spectral analysis, and muscle sympathetic nerve activity. CONCLUSIONS: This case suggests not only that reduction in blood pressure by microvascular decompression of the rostral ventrolateral medulla may be mediated by a decrease in sympathetic nerve activity but also that neurovascular compression of this area may be a cause of blood pressure elevation via increased sympathetic nerve activity.

Blood Pressure↗
PubMed1978

Distal decompression and proximal feeding for nutritional support during bowel obstruction.

The treatment for acute mechanical intestinal obstruction is a timely operation. A select group of patients may, however, be nutritionally supported with continual administration of elemental diet proximal to long tube decompression under two sets of circumstances: 1. while awaiting spontaneous or treatment-induced resolution of the underlying process, and 2. while reversing catabolism during evaluation prior to operation. Eleven patients with chronic intermittent bowel obstruction were studied: six with obstruction involving radiated small bowel, three with an acute exacerbation of chronic inflammatory bowel disease, one with obstruction secondary to an intra-abdominal phlegmon and one with a segmental motility problem. They received nutritional support with continual gastrointestinal administration of elemental diet proximal to long tube decompression after initial observation for signs or symptoms of altered intestinal viability and stabilization of fluid and electrolyte status. Six of the 11 patients eventually required operation. All patients maintained body weight and three gained weight. Mean nutritional input was 1,873 calories and 12.6 gm nitrogen/day. There were no complications related to the technique of proximal feeding and distal decompression because of careful patient selection and appropriate administration of elemental diet under carefully controlled guidelines.

Adult↗
PubMed2003

Translumbar extraperitoneal decompression for abdominal compartment syndrome after endovascular treatment of a ruptured AAA.

PURPOSE: To report an unusual case of abdominal compartment syndrome (ACS) following endovascular repair of a ruptured abdominal aortic aneurysm (rAAA) that had been treated with a stent-graft 3 years prior. CASE REPORT: A 68-year-old man with a 3-year-old Vanguard bifurcated aortic stent-graft experienced sudden back pain and collapse. Aneurysm rupture documented by computed tomography was due to dislocation of the left graft limb. A Talent aortomonoiliac graft was deployed, followed by a femorofemoral bypass. No endoleak was evident. A few hours later, the patient became oliguric and hemodynamically unstable. Increased intra-abdominal pressure (IAP) was recorded. Abdominal decompression was performed, removing 1500 mL of blood from the retroperitoneum through an 18-cm lumbotomy; the peritoneum was opened, and another 500 mL of blood was aspirated. The IAP fell immediately, followed by diuresis a few hours later. The patient recovered and was discharged after 27 days. CONCLUSIONS: Some of the perioperative complications seen after conventional rAAA repair are also encountered after endovascular treatment. ACS requires urgent decompression, and less invasive approaches, such as translumbar extraperitoneal decompression, may be a good alternative to a midline laparotomy.

Abdomen↗
PubMed2005

Alkalinisation of local anaesthetics prescribed for pain relief after surgical decompression of carpal tunnel syndrome.

PURPOSE: To compare the duration of analgesia achieved following administration of buffered prilocaine versus plain prilocaine to patients undergoing surgical decompression of the median nerve. METHODS: 40 (32 female and 8 male; mean age, 50.5 years) patients who underwent surgical decompression of carpal tunnel syndrome were recruited. Patients were randomly allocated to 2 groups: the alkalinised group was given 10 ml of prilocaine hydrochloride 2% buffered with 1 ml of sodium bicarbonate 8.4%, whereas the non-alkalinised group received 10 ml of plain prilocaine hydrochloride 2% solution. Patients were asked to rate their comfort level at the operation site in the first 6 hours following surgery and after discharge from hospital using a visual analogue scale (VAS). The duration of analgesic effect was evaluated every 3 hours. Additional oral analgesia in the form of paracetamol 500 mg tablets was available to patients if required for break-through pain. RESULTS: Significantly lower VAS scores were reported by the alkalinised group during the first postoperative 12 hours. The change of VAS scores over time was significantly higher in the non-alkalinised group. The mean analgesic requirement for paracetamol tablets in the alkalinised and non-alkalinised groups was 4 and 34, respectively. CONCLUSION: Buffered prilocaine provided a longer postoperative pain-free period for patients undergoing surgical decompression of the median nerve. It is easy, safe, and cost-effective.

Adult↗
PubMed1975

Mechanisms underlying spinal cord damage in decompression sickness.

Decompression sickness, which damaged the spinal cord, was produced in anesthetized dogs using a compression chamber. Cerebrospinal fluid pressure and several intravascular and intracardiac pressures were monitored during the course of the simulated dives. Manometric responses to forcible lung inflation and abdominal compression were measured both predive and postdive after signs of spinal cord damage were evident. Cinevenography of the epidural vertebral venous system was performed both predive and postdive. Histopathologic studies of the brains and cords of both predive and postdive. Histopathologic studies of the brains and cords of paretic animals were carried out. The results indicate that the epidural vertebral venous system becomes obstructed during spinal cord damaging decompression sickness and strongly suggests that spinal cord infarction in decompression sickness is caused by obstruction of cord venous drainage at the level of the epidural vertebral venous system.

Animals↗
PubMed1977

Neurologic and psychologic manifestations of decompression illness in divers.

It has been widely accepted that the neurologic sequelae of decompression illness are confined to the spinal cord. Of 10 divers who gave a history of an episode of decompression illness involving the central nervous system, we found that eight had unequivocal neurologic deficits implicating multiple supraspinal lesions. Seven of these neurologically impaired divers completed a battery of neuropsychologic tests that revealed severe deficits in all cases. The findings show that diffuse and multiple central nervous system lesions result from decompression illness and demonstrate the importance and close correlation of thorough neurologic and neuropsychologic tests in assessment following diving accidents.

Adult↗
PubMed1999

Arterial gas embolism after decompression: correlation with right-to-left shunting.

Paradoxical gas embolism is a possible cause of neurologic sequelae after decompression in divers. The authors detected arterial bubbles after decompression from chamber dives in two of six divers using transcranial Doppler sonography (TCD). Arterial bubbles correlated with the size of right-to-left shunting as diagnosed by contrast TCD. The pathway of spontaneous paradoxical embolism was tracked for the first time, supporting the concept of paradoxical gas embolism as a cause of early neurologic sequelae after decompression in at-risk divers.

Adult↗
PubMed2004

Chiari I malformation associated with ventral compression and instability: one-stage posterior decompression and fusion with a new instrumentation technique.

OBJECTIVE AND IMPORTANCE: We describe an alternative surgical technique for treatment of Chiari I malformation associated with ventral compression and instability of the region. An expansive suboccipital cranioplasty and a rigid occipitocervical fixation are performed in one stage. METHODS: The occipitocervical fixation is performed by use of metal rods fixed on the cranial side by screws inserted into the diploic layer of occipital bone and on the caudal side by screws inserted into the pedicle of the axis or in a transarticular fashion into the lateral masses of axis and atlas vertebra. A large piece of autologous bone is placed in the region between the rostral edge of cranial decompression and the axis, with the aim of achieving both expansive suboccipital cranioplasty and occipitocervical fusion. RESULTS: We performed this procedure in two patients with Chiari I malformation associated with basilar invagination and occipitalization of the atlas. Postoperatively, decompression of the brainstem and restoration of normal cerebrospinal fluid flow at the craniovertebral junction were confirmed radiologically, and the patients were relieved of their symptoms. At 1 and 3 years of follow-up, respectively, solid bone fusion was observed between the occipital bone and axis in both patients. CONCLUSION: Simultaneous posterior decompression and occipitocervical fixation with an alternative instrumentation technique is discussed. The procedure can be performed regardless of the size of suboccipital craniectomy. Screw insertion into the diploic layer of the occipital bone has not been described previously.

Adult↗
PubMed2005

Bulbar compression by an ectatic vertebral artery: a novel neurovascular construct relieved by microsurgical decompression.

OBJECTIVE: Brainstem compression caused by vascular abnormalities has rarely been reported in the literature. We describe five cases of large ectatic vertebral artery causing compression and distortion of the medulla oblongata with pyramidal tract signs and low cranial nerve dysfunction. Microvascular decompression by retracting the vertebral artery and anchoring it to the dura has been the treatment of choice. METHODS: Five patients, four male and one female, presented with progressive myelopathic features and lower cranial nerve dysfunction, especially dysphonia and dysphagia. Four patients were affected by systemic arterial hypertension. Magnetic resonance imaging showed impingement of the right vertebral artery in three patients and the left vertebral artery in two patients, on the right and left lateral medulla, respectively. In two patients, hypoplasia of the contralateral vertebral artery was documented. RESULTS: All patients underwent neurovascular decompression of the medulla oblongata. The ectatic and tortuous vertebral artery was detached from the medulla, shifted away, and repositioned by anchoring to the nearby dura mater using a Gore-Tex vascular slip. Postoperatively, all patients but one had improvement of their previous neurological symptoms. CONCLUSION: Brainstem dysfunction caused by a tortuous ectatic vertebral artery might be less uncommon than expected. It should be considered a new distinct clinical entity, the real incidence of which needs to be carefully evaluated by an appropriate diagnostic protocol, which includes primarily magnetic resonance imaging with specific three-dimensional sequences. Awareness of this condition is necessary to ensure the appropriate treatment. Surgical microvascular decompression seems very effective.

Aged↗
PubMed2005

Aggressive cranial vault decompression for cranial hyperostosis: technical case report of two cases.

OBJECTIVE AND IMPORTANCE: Camurati-Engelmann's disease, also known as progressive diaphysial dysplasia, is a disorder of the bone metabolism. Neurological manifestations of progressive diaphysial dysplasia include cranial nerve dysfunction, generalized weakness, cerebellar herniation, and increased intracranial pressure. In the past, surgical intervention has been of limited and temporary benefit. We present two patients with cranial hyperostosis secondary to Camurati-Engelmann's disease who were treated successfully with a single surgery involving a combination of multiple craniotomies for cranial vault decompression. CLINICAL PRESENTATION: Two patients presented with signs and symptoms of increased intracranial pressure secondary to Camurati-Engelmann's syndrome. Radiological workup revealed marked cranial hyperostosis. INTERVENTION: The patients underwent aggressive cranial vault decompression. Multiple craniotomies were performed, and the inner table was then drilled down until the bone was 1 cm thick. CONCLUSION: Effective surgical options are needed for clinically significant cranial hyperostosis. In an effort to further define operative management in these patients, we describe a single, aggressive surgical procedure that may be used for successful cranial decompression.

Adult↗
PubMed2005

Incidence and characteristics of spinal decompression surgery after the onset of symptoms of amyotrophic lateral sclerosis.

OBJECTIVE: The high incidence of spondylosis in patients at the mean age of onset (55.7 yr) of amyotrophic lateral sclerosis (ALS) can make recognition of ALS as a cause of weakness difficult. METHODS: To assess the impact of this diagnostic dilemma on neurosurgical practice, we performed a retrospective analysis of a database of more than 1500 patients with motor neuron disease. RESULTS: Of 1131 patients with typical, sporadic ALS, 47 (4.2%) underwent decompressive spinal surgery after the onset of retrospectively recognized symptoms of ALS. Among 55 operations in 47 ALS patients, 86% yielded no improvement, 9% produced minor improvement, and only 5% provided significant benefit. Cervical decompression was performed in 56%, lumbar in 42%, and thoracic in 2%. Foot drop was a symptom prompting surgery in 11 patients, and in 10, this finding was subsequently attributed solely to ALS. No differences between ALS patients who underwent spinal decompression and other ALS patients were noted regarding age at symptom onset, severity of impairment at time of diagnosis, or rate of disease progression. Not surprisingly, patients who had spinal surgery tended to have a longer interval between retrospectively recognized symptom onset and diagnosis of ALS. CONCLUSION: A small but significant number of patients with unrecognized ALS undergo spinal surgery that in retrospect may be inappropriate. The possibility of ALS must be considered in the evaluation of patients with weakness even in the presence of radiographic evidence of spondylosis and nerve root or spinal cord impingement.

Age Factors↗
PubMed2006

Extradural anterior clinoidectomy as an alternative approach for optic nerve decompression: anatomic study and clinical experience.

OBJECTIVE: We introduce pterional craniotomy extradural anterior clinoidectomy as a new alternative approach for optic nerve decompression in patients with traumatic optic neuropathy. METHODS: Intracranial structures pertinent to pterional craniotomy extradural anterior clinoidectomy were carefully studied in 10 dry craniums and 10 cranial bases with dura mater. Important parameters of these structures were measured. Stepwise dissections simulating pterional craniotomy extradural anterior clinoidectomy were performed in 20 cadaver heads bilaterally. Pterional craniotomy extradural anterior clinoidectomy was then applied to 12 patients (13 eyes) with traumatic optic neuropathy and severe visual dysfunction. RESULTS: The anatomic features and their variations of optic canal, ophthalmic artery, falciform ligament, and Zinn's ring (annular tendon) were studied and measured in detail. Extensive opening of the optic canal and optic nerve sheath was successfully achieved in all 12 patients without major surgical complications. Significant visual acuity improvement occurred in eight (nine eyes) out of our 12 patients after surgery. The surgical techniques and advantages of pterional craniotomy extradural anterior clinoidectomy for optic nerve decompression are presented and discussed in detail. CONCLUSION: Pterional craniotomy extradural anterior clinoidectomy is a promising new alternative approach for optic nerve decompression in patients with traumatic optic neuropathy.

Adolescent↗
PubMed2007

Preoperative simulation for microvascular decompression in patients with idiopathic trigeminal neuralgia: visualization with three-dimensional magnetic resonance cisternogram and angiogram fusion imaging.

OBJECTIVE: Precise assessment of the complex nerve-vessel relationship at the root entry zone of the trigeminal nerve is useful for planning microvascular decompression in patients with idiopathic trigeminal neuralgia. We have applied a fusion imaging technique of three-dimensional (3-D) magnetic resonance cisternography and co-registered 3-D magnetic resonance angiography (MRA) that allows virtual reality for the preoperative simulation of the neurovascular conflict at the trigeminal nerve root entry zone. METHODS: Fusion images of 3-D magnetic resonance cisternograms and angiograms were reconstructed by a perspective volume-rendering algorithm from the volumetric data sets of magnetic resonance cisternography, obtained by a T2-weighted 3-D fast spin echo sequence, and co-registered MRA, by a 3-D time-of-flight sequence. Consecutive series of 12 patients with idiopathic trigeminal neuralgia were studied with fusion 3-D magnetic resonance cisternogram and MRA in the preoperative assessment for the microvascular decompression of the affected trigeminal nerve. RESULTS: The complex anatomical relationship of the offending vessels to the trigeminal nerve root entry zone was depicted on the fusion 3-D magnetic resonance cisternogram and MRA. The presence of offending vessels and compressive site of neurovascular conflict was assessed from the various viewpoints within the cistern and was presumed by the preoperative simulation through the surgical access (surgeon's-eye view). The blinded surgical trajectory was discerned by the virtual image through the opposite direction projected from above (bird's-eye view). The 3-D visualization of the nerve-vessel relationship with fusion images was consistent with the intraoperative trajectory and findings. CONCLUSION: Fusion imaging of 3-D magnetic resonance cisternogram and MRA may prove a useful adjunct for the diagnosis and decision-making process to execute the microvascular decompression in patients with idiopathic trigeminal neuralgia.

Adult↗
PubMed2006

Long-term outcome of optic nerve encasement and optic nerve decompression in patients with fibrous dysplasia: risk factors for blindness and safety of observation.

OBJECTIVE: Fibrous dysplasia (FD) of bone may occur solely as a skeletal condition or it may occur in association with extraskeletal manifestations, including growth hormone (GH) excess. Uncertainty exists as to the management of FD involving the optic nerves. In an effort to clarify management, the authors studied a large population of patients. METHODS: One hundred four patients underwent an evaluation that included review of records, endocrine testing, cranial computed tomography, and neuro-ophthalmological examination. RESULTS: Ninety-one of 104 patients had craniofacial FD; complete records were available for 87 patients (174 nerves). Seventeen percent of the optic nerves were less than 50% encased, 22% were 50 to 99% encased, and 61% were 100% encased. Twelve percent of the nerves that were 100% encased showed evidence of optic neuropathy, but 88% did not. The group with optic neuropathy was not older than the group without. Patients with GH excess were significantly more likely to have nerves that were 100% encased (relative risk, 4.1; 95% confidence interval, 1.5-11.1; P = 0.0017) and to have optic neuropathy (relative risk, 3.8; 95% confidence interval, 2.0-7.1; P = 0.0019). Six prophylactic optic nerve decompressions were performed; in five patients, vision was stable after surgery, and one patient was blind after surgery. Thirteen interventional optic nerve decompression procedures were performed; six of the 13 patients showed some improvement and seven of the 13 showed no improvement or worsened vision. CONCLUSION: The vast majority of optic nerves encased with FD do not exhibit symptoms of optic neuropathy and seem to be stable over time. GH excess is associated with increased risk of nerve encasement and optic neuropathy. Patients with craniofacial FD should be screened for GH excess, and optic nerve decompression should be performed only when there is objective evidence of progressive optic neuropathy.

Adolescent↗