Table Of ContentProceedings of the
8th European Congress
of Neurosurgery
Barcelona) September 6-11) 1987
Edited by
F. Isamat) A. Jefferson) F. uew) L. Symon
Volume 2
Spinal Cord and Spine Pathologies
Basic Research in Neurosurgery
Acta Neurochirurgica
Supplementum 43
Springer-Verlag Wien New York
Professor Dr. Fabian Isamat
Servicio de Neurocirugia, Hospital de Bellvitze, University of Barcelona, Barcelona, Spain
Dr. Antony Jefferson
Newport, Dyfed, United Kingdom
Professor Dr. Friedrich Loew
Neurochirurgische UniversiHitsklinik, Homburg/Saar, Federal Republic of Germany
Professor Lindsay Symon, TD, FRCS
Department of Neurological Surgery, Institute of Neurology, The National Hospital, London, U.K.
With 97 Figures
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© 1988 by Springer-VerlagJWien
Softcover reprint of the hardcover 1s t edition 1988
Library of Congress Cataloging-in-Publication Data. European Congress of Neurosurgery (8th: 1987: Barcelona, Spain) Proceedings of the 8th European Congress
of Neurosurgery: Barcelona, September 6--11, I 987Jedited by F. Isamat ... [etal.]. VIII, 213 p. 21 x 27.7 cm.-(Acta neurochirurgica. Supplementum, ISSN 0065-
1419;43).ISBN-13:978-3-7091-8980-1 (U.S.:v.2).I.Nervous system-Surgery-Congresses.L Isamat,F. II.Title.IILSeries. [DNLM: I. Neurosurgery---congresses.
WI AC8661 no.43JWL368 E89p 1987]. RD593.E95 1987. 617'.48-dcI9. 88-20167.
ISSN 0065-1419
ISBN-13:978-3-7091-8980-1 e-ISBN -13 :978-3-7091-8978-8
DOl: 10.1007/978-3-7091-8978-8
Preface
The 8th European Congress of Neurosurgery which took place in Barcelona from September 6 to
11, 1987, was an unforgettable experience. Many factors contributed to its success: the splendid ambience
of Barcelona, the generous hospitality and warm friendship of the hosts, and the marvellous organization
and high scientific standard of papers, workshops and discussions.
For financial reasons it would not have been possible to publish all the papers presented during the
congress. In order to preserve as much as possible of the scientific results, the Programme Committee
of the European Association of Neurosurgical Societies had already selected before the congress a
certain number of abstracts to be published as full papers. These are compiled in two supplement
volumes of Acta Neurochirurgica and deal with the following main topics:
Volume 1: 1. Intraoperative and posttraumatic monitoring and brain protection
2. Cerebro-vascular lesions
3. Intracranial tumours
4. Benign intracranial cystic lesions, hydrocephalus, CSF-volumes
5. Central pain syndromes
Volume 2: 6. Spinal cord and spine pathologies
7. Basic research in neurosurgery.
The Editors
F. Isamat, A. Jefferson, F. Loew, L. Symon
Contents Listed in Current Contents
VI. Spinal Cord and Spine Pathologies
Fornari, M., Pluchino, F., Solero, C. L., Giombini, S., Luccarelli, G., Oliveri, G., Lasio, G.: Microsurgical
Treatment of Intramedullary Spinal Cord Tumours . . . . . . . . . . . . . . . . . . . .. 3
Yasui, T., Hakuba, A., Katsuyama, 1., Nishimura, S.: Microsurgical Removal of Intramedullary Spinal
Cord Tumours: Report of 22 Cases . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9
Roosen, N., Dahlhaus, P., Lumenta, Ch. B., Lins, E., Stork, W., Gahlen, D., Bock, W. 1.: Magnetic
Resonance (MR) Imaging in the Management of Primary and Secondary Syringomyelic Cavities, and
of Other Cystic Lesions of the Spinal Cord . . . . . . . . . . . . . . . . . . . . . . . .. 13
Powell, M.: Syringomyelia: How MRI Aids Diagnosis and Management ............. 17
Tokuno, H., Hakuba, A., Suzuki, T., Nishimura, Sh.: Operative Treatment of Chiari Malformation with
Syringomyelia .................................... 22
Bidzinski, 1.: Pathological Findings in Suboccipital Decompression in 63 Patients with Syringomyelia 26
Bidzinski, 1.: Late Results of the Surgical Treatment of Syringomyelia . . . . . . . . . . . . . 29
Philipp on, 1., Sangla, S., Lara-Morales, 1., Gazengel, 1., Rivierez, M., Horn, Y. E.: Treatment of Syrin-
gomyelia by Syringo-peritoneal Shunt . . . . . . . . . . . . . . . . . . . . . . . . . .. 32
Alphen, H. A. M. van, Braakman, R., Berfelo, M. W., Broere, G., Bezemer, P. D., Kostense, P. 1.:
Chemonucleolysis or Discectomy? Results of a Randomized Multicentre Trial in Patients with a Her-
niated Lumbar Intervertebral Disc. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 35
Ferrer, E., Garcia-Bach, M., Lopez, L., Isamat, F.: Lumbar Microdiscectomy: Analysis of 100 Consecutive
Cases. Its Pitfalls and Final Results . . . . . . . . . . . . . . . . . . . . . . . . . . .. 39
Cervellini, P., Curri, D., Bernardi, L., Volpin, L., Benedetti, A.: Computed Tomography After Lumbar
Disc Surgery: a Comparison Between Symptomatic and Asymptomatic Patients 44
Ray, Ch. D.: Transfacet Decompression with Dowel Fixation: a New Technique for Lumbar Lateral
Spinal Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 48
Gomes, F.: Automated Percutaneous Nucleotomy-Initial Experience in Twenty-Five Cases of Contained
Lumbar Disc Herniation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 55
Onik, G., Maroon, 1., Day, A., Helms, c.: Automated Percutaneous Discectomy: Preliminary Experience 58
Sonntag, V. K. H., Hadley, M. N., Dickman, C. A., Browner, C. M.: Atlas Fractures: Treatment and
Long-term Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 63
Spetzler, R. F., Hadley, M. N., Sonntag, V. K. H.: The Transoral Approach to the Anterior Superior
Cervical Spine. A Review of 29 Cases . . . . . . . . . . . . . . . . . . . . . . . . . .. 69
Gambacorta, D., Reale, F.: Posterior Acrylic Surgical Fixation of Odontoid Fractures .. . . . .. 75
Zygmunt, S. c., Ljunggren, B., Alund, M., Brattstrom, H., Saveland, H. G., Holtas, S., Larsson, E. M.,
Redlund-lohnell, I.: Realignment and Surgical Fixation of Atlanto-axial and Sub axial Dislocations in
Rheumatoid Arthritis (RA) Patients . . . . . . . . . . . . . . . . . . . . . . . . . . .. 79
Steudel, W.I., Rosenthal, D., Lorenz, R., Merdes, W.: Prognosis and Treatment of Cervical Spine Injuries
with Associated Head Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 85
Rochkind, S., Barr-Nea, L., Bartal, A., Nissan, M., Lubart, R., Razon, N.: New Methods of Treatment
of Severely Injured Sciatic Nerve and Spinal Cord. An Experimental Study 91
Zierski, 1., Miiller, H., Dralle, D., Wurdinger, T.: Implanted Pump Systems for Treatment of Spasticity 94
VII. Basic Research in Neurosurgery
Shibata, T., Burger, P. c., Kleihues, P.: Ki-67 Immunoperoxidase Stain as Marker for the Histological
Grading of Nervous System Tumours . . . . . . . . . . . . . . . . . . . . . . . . . .. 103
Westphal, M., Hansel, M., Nausch, H., Rohde, E., Koppen, 1., Fiola, M., Holzel, F., Herrmann, H.-D.:
Glioma Biology in vitro: Goals and Concepts . . . . . . . . . . . . . . . . . . . . . . .. 107
VIII Contents
Casalone, R., Minelli, A., Butti, G., Gaetani, P., Silvani, V., Solero, C. L., Danesino, C.: Gene Dosage
Effect in Cells with Monosomy of Chromosome 22 Derived from Human Meningiomas ..... 114
Helseth, E., Unsgaard, G., Dalen, A., Vik, R.: The Effect of Type Beta Transforming Growth Factor on
Proliferation of Clonogenic Cells from Human Gliomas .. , . . . . . . . . . . . . . . .. 118
Colombatti, M., Bisconti, M., Lorenzi, P., Stevanoni, G., Dipasquale, B., Gerosa, M., Tridente, G.:
Human Glioma Cell Lines: Tumour Associated Antigens Distribution and Sensitivity to Antibody-
Toxin or Ligand-Toxin Conjugates. A Preliminary Report . . . . . . . . . . . . . . . . .. 121
Gaini, S. M., Riboni, L., Cerri, c., Grimoldi, N., Sganzerla, E. P., Berra, B.: Ganglioside Content and
Composition in Human Gliomas . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 126
Maleci, A., Ausiello, c., Gagliardi, F. M., Guidetti, B., Cassone, A.: The Response of Peripheral Blood
Mononuclear Cells of Glioma-Bearing Patients to Stimulation with Microbial Antigen and IL-2:
Proliferation and IFN-Gamma Production . . . . . . . . . . . . . . . . . . . . . . . .. 130
Imielinski, B. L., Borowska-Lehman, J., Zohowska, A.: Immunological and Immunohistochemical Studies
in Brain Tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 135
Hirakawa, K., Naruse, Sh., Higuchi, T., Horikawa, Y., Tanaka, Ch., Ebisu, T.: The Investigation of
Experimental Brain Tumours Using 31p_MRS and IH-MRI . . . . . . . . . . . . . . . . 140
Rommel, Th., Bodsch, W.: Glucocorticosteroid Treatment of Va so genic Oedema . . . . . . . . .. 145
Shimizu, K., Tsuda, N., Okamoto, Y., Matsui, Y., Miyao, Y., Tamura, K., Yamada, M., Nakatani, S.,
Ikeda, T., Mogami, H.: Transplant-induced Recovery from 6-OHDA Lesions of the Nigrostriatal
Dopamineneurones in Mice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 149
Takayama, H., Toya, Sh., Shinozaki, T., Inoue, H., Otani, M., Kohsaka, Sh., Tsukada, Y.: Possible
Synapse Formation by Embryonic Cerebellar Tissue Grafted into the Cerebellum of the Weaver Mutant
Mouse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 154
Gonzalez-Darder, J. M., Barcia-Salorio, J. L., Barbera, J., Broseta, J.: Intraventricular Transplantation
of Omentum for Treatment of Hydrocephalus. An Experimental Study in Dogs . . . . . . . .. 159
Rijen, P. C. van, Verheem, A., Tulleken, C. A. F.: Proton Magnetic Resonance Imaging in Experimental
Cerebral Ischaemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 162
Langmoen,1. A., Berg-Johnsen, J.: Intracellular Recordings from Neurones in Rat Cerebral Cortex During
Hypoxia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 168
Higuchi, T., Naruse, S., Horikawa, Y., Tanaka, c., Ebisu, T., Yamamoto, K., Hirakawa, K.: Pathophys
iological Investigation of Experimental Cerebral Ischaemia Using in vivo 31p_NMR Spectroscopy and
IH-MRI ....................................... , 172
Rodriguez y Baena, R., Gaetani, P., Silvani, V., Spanu, G., Marzatico, F.: Effect of Nimodipine on
Mitochondrial Respiration in Different Rat Brain Areas After Subarachnoid Haemorrhage . . .. 177
Wallenfang, Th., Fries, G., Jantzen, J. P., Bayer, J., Trautmann, F.: Pathomechanism of Brain Oedema
in Experimental Intracerebral Mass Haemorrhage . . . . . . . . . . . . . . . . . . . . .. 182
Doczi, T., Joo, F., Szerdahelyi, P., Bodosi, M.: Regulation of Brain Water and Electrolyte Contents: the
Opposite Actions of Central Vasopressin and Atrial Natriuretic Factor (ANF). . . . . . . . .. 186
Roda, J. M., Alvarez, F., Garcia-Villalon, A. L., Ruiz, M. R., Gutierrez, M., Garcia Blazquez, M.: An
Increment in Unilateral Carotid Blood Flow Produces Cerebral Aneurysms in Rats ....... 189
Moringlane, J. R., Grote, R., Vonnahme, F.-J., Mestres, P., Harbauer, G., Ostertag, C. B.: Occlusion of
Experimental Artery Aneurysms by Intrasaccular Injection of Fibrin Sealant .... . . . . .. 193
Broseta, J., Garcia-March, G., Sanchez-Ledesma, Ma. J., Gon~alves, J., Anaya, J., Torregrosa, A., Urbano,
J., Collia, F., Ludeiia, Ma. D., Merch:in, M.: Local Pathological Findings in Experimental Dorsal
Root Entry Zone Lesions Performed by Mechanical Section, Laser and Radiofrequency. A Comparative
Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 198
Barbera, J., Gonzalez, J., Gil, J. L., Sanjuan, Ma. A., Garcia, F., Lopez, A.: The Quality and Extension
of Nerve Fibre Regeneration in the Centrocentral Anastomosis of the Peripheral Nerve . . . . .. 205
Pallini, R., Fernandez, E., Minciacchi, D., Marchese, E., Sbriccoli, A.: Peripheral Nerve Autografts to
the Rat Spinal Cord: a Study of the Origin of Regenerating Fibres Using Fluorescent Double Labelling 210
VI. Spinal Cord and Spine Pathologies
Acta Neurochirurgica, Supp\. 43, 3-8 (1988)
© by Springer-Verlag 1988
Microsurgical Treatment of Intramedullary Spinal Cord Tumours
M. Fornari, F. Pluchino, C. L. Solero, S. Giombini, G. Luccarelli, G. Oliveri, and G. Lasio
Department of Neurosurgery, Istituto Neurologico "C. Besta", Milano, Italy
Summary lesions appear still extremely controversial. A general
agreement has been reached concerning the treatment
A series of 81 patients operated for intramedullary spinal cord tu
mours over a span of 12 years (1975-1986) is presented. The mean of ependymoma, whose complete removal is achievable
age of the patients was about 37 years and 9 patients were in the without additional damage to the spinal cord in most
paediatric age (0-15 years). In 29 cases (36%) the tumours were of the cases, in spite of the frequent huge longitudinal
located within the cervical region; in 34 cases the tumours were
extent of these tumours. On the other hand the suc
located in the thoracic region (42%) and in 18 cases the tumours
cessful removal of astrocytoma has been reported in
were located within the medullary cone (22%). Ependymoma ac
counted for 52% of the cases (42 cases), astrocytoma for 20% (16 very few series and it has been mostly related to as
cases), lipoma for 7% (6 cases), hemangioblastoma for 6% (5 cases), trocytoma in childhood, even if holointramedullary\
metastatic tumours for 5% (4 cases); in the remaining 8 cases (10%) it has been claimed that these tumours should have a
rare or very rare spinal tumours were found. The 9 patients in the
well defined plane of cleavage from neural tissue in
paediatric age and 8 additional cases who had undergone previous
surgery were then excluded from this review. In 59% of the patients approximately 50% of adult patientsll. The aim of this
with ependymoma and in 90% of the patients with astrocytoma work was to review our series of 81 patients with in
severe neurological deficit were already present before the operation. tramedullary tumours operated during the period from
Total tumour removal was accomplished in 81 % of the cases 1975 to 1986 with main regard to the possible factors
with ependymoma, total or subtotal removal was achieved in 50%
influencing the long term clinical outcome.
of the cases with astrocytoma.
At long term follow-up study fair or good functional results were
observed in 19 out of 41 cases of ependymoma (46%) and in 3 cases Material and Methods
out of 10 of astrocytoma (30%). The surgical outcome was mostly
During the last 12 years (1975-1986), 81 patients with intramedullary
related to the preoperative neurological conditions and to tumour
spinal cord tumours have been operated at the Istituto Neurologico
malignancy grade.
"C. Besta" of Milano. Fourty-eight patients were males and 34 were
females. The age of the patients ranged from 5 to 62 years (mean
Keywords: Spinal cord neoplasms; astrocytoma; ependymoma; age about 37 years); 9 patients were in the paediatric age (0-15 years)
microsurgery; follow-up studies. and were excluded from this study (5 ependymoma and 4 astrocy
toma). Patients in adolescent and juvenile age (15-20 years) showed
clinical and pathological conditions similar to those of the adult
Introduction
patients and have not therefore been differentiated from them.
In spite of the fact that the surgical removal of intra The diagnosis was mostly reached by myelography, although the
medullary tumours had been pioneered by some neu combination of this examination with CT scanning resulted in useful
additional information in many cases. During the last few years the
rosurgeons, mainly by Cushing, Gowers, Elsberg,
early recognition of these lesions and the differential diagnosis from
Horraxl,3,6,9, since 1925, the first large series of patients syringomyelia, multiple sclerosis and inflammatory diseases have
in which successful removal of intramedullary tumours been impressively improved by the aid of Magnetic Resonance Im
was performed was reported by Greenwood7 only aging (MRI) (Fig. 1).
about 40 years later. Later on microsurgical techniques In 29 cases (36%) the tumours were located in the cervical region,
in 34 cases the tumours were located in the thoracic region (42%)
were widely introduced in the neurosurgical practice
and in 18 cases (22%) the tumours were located in the lumbosacral
but nevertheless only very few series of treated intra
region within the conus medullaris often extending towards the cauda
medullary tumours have then been reported2, 4, 5, 8, 10, equina (14 cases) (see also Table 1). As far as the histological clas
II, 12 and the indications and results of surgery of these sification is concerned, ependymoma accounted for 52% of the cases
4 M. Fornari et at.: Microsurgical Treatment of Intramedullary Spinal Cord Tumours
Fig. 1. MRl in a case of cervical in
tramedullary lipoma. The tumour and
its relationship with the spinal cord are
clearly outlined. An exophytic portion
of the tumour was also extending ex
tramedullary from the dorsal surface
of the spinal cord
(42 cases), astrocytoma accounted for 20% of the cases (16 cases), segments or longer (in two cases holointramedullary astrocytoma
lipoma accounted for 7% of the cases (6 cases), hemangioblastoma were present). Astrocytomas were mostly (69%) found in the thoracic
accounted for 6% of the cases (5 cases), metastatic tumours ac region while ependymoma were found with about the same frequency
counted for 5% of the cases (4 cases), in the remaining 8 cases rare in the cervical and thoracic region. The lumbosacral region was fairly
(epidermoid tumours: 3 cases) or very rare intramedullary tumours typical for the epidermoid tumours (3 cases). All the patients have
were found (10%). In 21 cases the tumours were found extending been operated by microsurgical technique; the tumours located in
for 3 to 6 vertebral segments and in 6 cases (7%) for 7 vertebral the cervical region were mostly operated with the patient in the sitting
Table 1
Ependymoma Astrocytoma Lipoma Hemangio- Epidermoid Metastatic Rare T.
blastoma
Cervical 29 17 5 2 3
Region cases
Thoracic 34 13 11 4 4
Region cases
Lumbosacral 18 12 3 2
Region cases
Tot 81 42 16 6 5 3 4 5
cases
M. Fornari et al.: Microsurgical Treatment of Intramedullary Spinal Cord Tumours 5
Fig. 2. Operative photograph showing the
cavity left within the spinal cord after
complete removal of an intramedullary
ependymoma. The borders of the mye
lotomy stay open also after removal of
pial stay sutures
position (with ultrasonic cardiac monitor in use and intravenous in bowel, bladder and sexual organs dysfunction in 3
catheter inserted to prevent air embolism), while in the other cases cases (10%). The mean duration of the clinical history
the patients were carefully adjusted in the prone position in order
was fairly long, lasting for about 53 months (range: 1
to obtain a free abdomen and chest and therefore minimizing the
month-15 years). At time of the operation the neu
venous congestion around the area of surgery.
rological examination was normal or showed only mild
sensory and motor deficits in 13 patients (41 %); in 18
Results
cases (59%) severe or devastating neurological deficits
In consideration of the different clinical and surgical (up to paraplegia) were already present before surgery.
problems which arise when dealing with intramedullary In one case sudden worsening of symptoms and signs
tumours of different type, it looked worthwhile to ana was observed after myelography. Complete tumour re
lyze the results of this series according to the tumour moval was achieved in 25 cases (81 %) while subtotal
type. removal was accomplished in the remaining 6 cases
i) Ependymoma (31 cases): ependymoma was the (19%) (Fig. 2), due to the difficulties encountered in
most relevant group in this series (42 patients: 52%). the dissection of the tumour from the surrounding
Eleven patients were then excluded from this study spinal cord tissue. According to the histological ex
because they were in the paediatric age (5 cases) or amination 25 cases were classified as ependymoma, 2
because they had been previously operated elsewhere cases as subependymoma, 4 cases as anaplastic epen
(6 cases). Finally 31 patients have been considered: 15 dymoma or ependymoblastoma. A huge cranial or cau
were females and 16 were males and the mean age was dal cystic cavity was encountered in 7 cases. Out of the
39 years. The tumours were located in the cervical 13 patients with absent to mild neurological deficits,
region in 7 cases (23%), in the cervico-thoracic region one presented severe neurological worsening in the im
in 9 cases (29%), in the thoracic region in 6 cases (19%), mediate postoperative course, which did not clear in
in the conus medullaris region in 9 cases (29%). The spite of adequate rehabilitation therapy. Two other of
tumour extended for 1-2 spinal segments in 4 patients; these patients with anaplastic ependymoma presented
for 3 to 5 segments in 15 cases; for more than 5 segments clinical progression of the disease because of the rapid
in 12 cases. The first symptom consisted in sensory regrowth of the tumours within 2 and 3 years respec
disturbances (pain, paresthesia or hypoesthesia) in 23 tively. The remaining 10 patients at long-term follow
patients (74%), in motor deficits in 5 cases (16%) and up study (mean duration 62 months) were doing fairly
