Background:Hardware failure or malfunction after deep brain stimulation is an infrequent but costly occurrence with currently available systems.Case Description:The authors present the case of a 65-year-old female patient with predominantly tremoric Parkinson's disease who, 4 months after bilateral subthalamic nucleus stimulation with very good clinical results, began to display signs of recurrent disease and an increasingly smaller response to stimulation. Radiological studies, changes in electrode impedance and surgical findings and results established the diagnosis of Twiddler syndrome. Close patient follow-up, lack of a psychiatric history and physical examination findings were, however, contrary to the previously described causative mechanism.Conclusion:The clinical and radiological setup of Twiddler syndrome must be readily recognized. Its causative mechanism should remain under discussion, and intraoperative technical details may help to explain its occurrence.

BACKGROUND: Most studies concerning intraoperative temporary arterial occlusion overlook the period between and after clip placement. OBJECTIVE: To analyze the brain tissue oxygen tension through the process by which anterograde arterial blood flow is re-established after temporary clipping (TR). METHODS: In this prospective observational study, patients who presented to surgery for middle cerebral artery aneurysms were continuously monitored with ICM+, to obtain temporal (downstream) P bt O 2 levels while M1 segment temporary clips were applied and removed. P bt O 2 changes were analyzed and compared with the clipping phase, and measures of exposure to hypoxia were defined and assessed during both phases and used in a model to test the impact of extending them. RESULTS: Eighty-six TRs (20 patients) were recorded. The mean acquired amount of time per clip release (CR) event was 336.7 seconds. Temporary clip removal produced specifically shaped, highly individual P bt O 2 curves that correlated with their corresponding clipping phase events but developing slower and less consistently. The CR phase was responsible for greater cumulative exposure to hypoxia than the clip application phase through the first and second minutes of each. In our model, the duration of the TR phase was mostly responsible for the total exposure to hypoxia, and longer CR phases reduced the mean exposure to hypoxia. CONCLUSION: During the clip removal phase, the brain tissue is still exposed to oxygen levels that are significantly below the baseline, reverting through a singular, dynamic process. Therefore, it must be regarded by surgeons with the same degree of attention as its counterpart.

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Endoscopic adhesiolysis is a potentially useful treatment for the relief of chronic intractable low back and lower limb pain in patients with previous lumbar spine surgery and epidural fibrosis. The use of larger volumes of saline during endoscopy and the employment of radiofrequency for the lysis of epidural adhesions are safe procedures, which may provide an additional benefit to the intervention.

Background:The occurrence of brain ischemic lesions, due to temporary arterial occlusion or incorrect placement of the definitive clip, is a major complication of aneurysm surgery. Temporary clipping is a current technique during surgery and there is no reliable method of predicting the possibility of ischemia due to extended regional circulatory interruption. Even with careful inspection, misplacement of the definitive clip can be difficult to detect. Brain tissue oxygen concentration (PtiO2) was monitored during surgery of middle cerebral artery (MCA) aneurysm presenting with subarachnoid hemorrhage (SAH), for detection of changes in brain oxygenation due to reduced blood flow, as a predictor of ischemic events, during temporary clipping and after definitive clipping.Methods:PtiO2 was monitored during surgery of 13 patients harboring MCA aneurysms presenting with SAH, using a polarographic microcatheter (Licox, GMS, Kiel, Germany) placed in the territory of MCA.ResultsA decrease in PtiO2 values was verified in every period of temporary clipping. Brain infarction occurred in 2 patients; in both cases, there was a decrease in PtiO2 greater than 80% from basal value, a minimum value of less than 2 mmHg persisting for 2 or more minutes during temporary clipping, and an incomplete recovery of PtiO2 after definitive clipping. In 2 patients, incomplete recovery of values after definitive clipping led to verification of inappropriate placement and repositioning of the clip.Conclusion:The results suggest that intraoperative monitoring of PtiO2 may be a useful method of detection of changes in brain tissue oxygenation during MCA aneurysm surgery. Postoperative infarction in the territory of MCA developed in cases with an abrupt decrease of PtiO2 and a very low and persistent minimum value, during temporary clipping, and an incomplete recovery after definitive clipping. Verification of clip position should be considered when there is an incomplete recovery or a persistent fall in PtiO2 after definitive clipping.

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Background:The role of laminectomy in the surgical treatment of cervical spondylotic myelopathy (CSM) is established even though postoperative cervical sagittal balance changes and a risk for long-term instability have been described. The aim of the present study is to investigate its clinical efficacy and the radiological outcome in the long-term.Methods:The authors retrospectively reviewed consecutive cases of patients with CSM, who underwent cervical laminectomy between 1995 and 2010 at the Hospital São João (n = 106). Clinical files were consulted, and the patients reassessed in order to collect information on complaints, previous neurological deficits, surgery and its complications. Subjective and objective clinical evaluation (by three myelopathy scores) and imaging studies were undertaken in order to assess the long-term cervical sagittal curvature and presence of instability.Results:After applying exclusion criteria, 57 patients were able to complete the follow-up. A favorable statistically significant difference was obtained when comparing clinical scores. Ninety-one percent of patients were satisfied with the outcome of the surgery. Only 1 patient developed kyphosis according to Ishihara index and none according to the method of Matsumoto. Four patients developed subclinical cervical instability. No clinical-imaging correlation was found.Conclusions:If patients are properly selected cervical laminectomy without additional instrumentation is effective in offering a clinical improvement to patients with CSM with a low incidence of clinically significant radiological deterioration.

The finding of low intraoperative basal PbtO(2) values may be an indicator for a high risk of occurrence of post-operative TCD vasospasm in cases of aneurysmatic SAH.