J K Krauss

Publications of J K Krauss

• Selective thoracic ganglionectomy for the treatment of segmental neuropathic pain.

  Authors: R Weigel, H H Capelle, M Schmelz, J K Krauss

  European journal of pain (London, England). 03/2012;

  Segmental thoracic neuropathic pain (NeuP) remains particularly difficult to treat. Sensory ganglionectomy was reported to alleviate NeuP. The experience with thoracic ganglionectomy, however, isSegmental thoracic neuropathic pain (NeuP) remains particularly difficult to treat. Sensory ganglionectomy was reported to alleviate NeuP. The experience with thoracic ganglionectomy, however, is very limited. Here, we report the results of a prospective pilot study in patients with incapacitating segmental thoracic NeuP treated by selective ganglionectomy. Seven patients were included suffering from refractory NeuP scoring 8 or more on a visual analogue scale (VAS). Every patient had test anaesthesia prior to surgery yielding more than 50% pain relief. The spinal ganglion was excised completely via an extraforaminal approach. Mean preoperative VAS scores were 9.1 (maximum pain); 5.4 (minimum pain); 7.9 (pain on average); 6.9 (pain at the time of presentation); and 7.4 (allodynia). Early post-operatively, there was a marked improvement of mean scores: 1.7; 0.7; 1.2; 1.0; and 0.7, respectively. One patient developed a mild transient hemihypaesthesia. In three patients, substantial pain occurred in a formerly unaffected dermatome within 1 year. Two of these patients had significant pain relief by a second operation. At the time of last follow-up at a mean of 24 months after the first procedure, mean VAS scores were 6.3; 2.1; 4.3; 4.0; and 1.3. Overall, medication was reduced. The patients rated their outcome as excellent (1), good (2), fair (2) and nil (2) with best improvement for allodynia. Selective thoracic ganglionectomy is a safe and partially effective procedure in selected patients albeit there may be partial recurrence of pain. Recurrent pain may affect dermatomes that were not involved initially.

• GPi-DBS may induce a hypokinetic gait disorder with freezing of gait in patients with dystonia.

  Authors: C Schrader, H-H Capelle, T M Kinfe, C Blahak, H Bäzner, G Lütjens, D Dressler, J K Krauss

  Neurology. 08/2011; 77(5):483-8.

  Stimulation-induced hypokinetic gait disorders with freezing of gait (FOG) have been reported only recently as adverse effects of deep brain stimulation (DBS) of the globus pallidus internus (GPi) inStimulation-induced hypokinetic gait disorders with freezing of gait (FOG) have been reported only recently as adverse effects of deep brain stimulation (DBS) of the globus pallidus internus (GPi) in patients with dystonia. The aim of this work was to determine the frequency and the nature of this GPi-DBS-induced phenomenon. We retrospectively screened our database of patients with dystonia who underwent DBS. Patients with focal, segmental, or generalized dystonia of primary or tardive origin and no gait disorder due to lower limb dystonia before DBS, bilateral pallidal stimulation, and a follow-up for more than 6 months were included. Reports of adverse events were analyzed, and gait abnormalities were scored by comparing preoperative and postoperative video recordings using Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS) items 3.10 (gait) and 3.11 (FOG). To assess the role of GPi-DBS in gait abnormalities, DBS was paused for 24 hours. Gait and FOG were assessed 30 minutes, 2 hours, and 24 hours after restarting DBS. Finally, a standardized adjustment algorithm was performed trying to eliminate the gait disorder. Of a collective of 71 patients with dystonia, 6 presented with a new gait disorder (8.5%; 2 men, 4 women, mean age 61.3 years [48-69 years], 2 craniocervical, 1 DYT-1 segmental, 1 truncal, 2 tardive dystonia). GPi-DBS improved Burke-Fahn-Marsden Dystonia Rating Scale motor score by 54% and disability score by 52%. MDS-UPDRS item 3.10 worsened from 0.5 (±0.8) to 2.0 (±0.9) and item 3.11 from 0 to 2.5 (±0.5). The gait disorder displayed shuffling steps and difficulties with gait initiation and turning. Increasing voltages improved dystonia but triggered FOG, sometimes worsening over a period of a few hours. It vanished within minutes after ceasing DBS. Electrode misplacement was ruled out. In all but one patient, no optimal configuration was found despite extensive testing of settings (monopolar, bipolar, pulse width 60-210 μs, frequency 60-180 Hz). Nevertheless, a compromise between optimal stimulation for dystonia and eliciting FOG was achieved in each case. A hypokinetic gait disorder with FOG can be a complication of GPi-DBS.

• Battery lifetime in pallidal deep brain stimulation for dystonia.

  Authors: C Blahak, H-H Capelle, H Baezner, T M Kinfe, M G Hennerici, J K Krauss

  European journal of neurology : the official journal of the European Federation of Neurological Societies. 12/2010; 18(6):872-5.

  The aim of the study was to analyse the lifetime of Soletra implantable pulse generators (IPG) in deep brain stimulation (DBS) of the globus pallidus internus (GPi) for dystonia, depending onThe aim of the study was to analyse the lifetime of Soletra implantable pulse generators (IPG) in deep brain stimulation (DBS) of the globus pallidus internus (GPi) for dystonia, depending on stimulation parameters and the total electrical energy delivered (TEED) by the IPG. In a prospective series of 20 patients with GPi DBS for dystonia, we recorded IPG longevity and stimulation parameters over time. An evaluation of the TEED was performed using the previously suggested equation [(voltage(2) × pulse width × frequency)/impedance] × 1 s. During median follow-up of 57 months (range 23-79 months), 64 IPGs were replaced because of battery depletion or end of life signal. We found a mean IPG longevity of 25.1 ± 10.1 (range 16-60) months, which was inversely correlated with the TEED (r = -0.72; P < 0.001). IPG longevity was not different between bipolar and monopolar stimulation (24.9 ± 10.8 vs. 25.4 ± 9.0 months, P = 0.76). Incongruously, the mean TEED applied throughout the lifetime cycle was significantly higher in patients with bipolar compared with monopolar stimulation (584 ± 213 vs. 387 ± 121 Joule; P < 0.01). Battery lifetime in GPi DBS for dystonia is substantially shorter compared with that reported in DBS for Parkinson's disease, caused by a considerably higher voltage and greater pulse width and therefore a higher TEED applied during the battery lifetime cycle. The commonly used equation to calculate TEED, however, seems to be correct only for monopolar, but not bipolar stimulation.

• Surgical treatment of dystonia.

  Authors: J K Krauss

  European journal of neurology : the official journal of the European Federation of Neurological Societies. 07/2010; 17 Suppl 1:97-101.

  Surgical treatment of dystonia has experienced a tremendous change over the past decade. Whilst selective peripheral denervation is reserved for cervical dystonia refractory to botulinum toxinSurgical treatment of dystonia has experienced a tremendous change over the past decade. Whilst selective peripheral denervation is reserved for cervical dystonia refractory to botulinum toxin injections, deep brain stimulation (DBS) of the pallidum has gained a wide scope and presents an elementary column in the treatment of medically refractory patients, nowadays. There is consensus that idiopathic generalized, cervical and segmental dystonia are good indications for DBS, although there is still a paucity of studies providing high-level data according to EBM criteria. Efficacy is maintained on longterm. Several other forms of primary dystonia are still under investigation but it appears that patients with Meige syndrome and myoclonus-dystonia gain also marked benefit. Study of the outcome in secondary dystonia disorders is more complex, in general, but patients with tardive dystonia gain similar improvement than patients with idiopathic dystonia. Overall, the risk profile of pallidal DBS is quite low, and it has been shown to be cognitively safe. The effect of pallidal DBS on non-dystonic extremities has not received much attention, albeit there are hints for a pro-akinetic mechanism. Several questions remain to be solved including optimal programming of stimulation settings, battery drain with high stimulation energies and the elucidation of the mechanisms of DBS in dystonia.

• Interdural epidermoid of the cavernous sinus.

  Authors: K Ghaemi, M J Mirzayan, J K Krauss

  Central European neurosurgery. 03/2010; 71(3):155-6.

• Training chart in movement disorders surgery added competence: as approved by the ESSFN and UEMS Section of Neurosurgery (March 2009).

  Authors: J K Krauss, B Broggi, H J Reulen, T Trojanowski, Y Lazorthes

  Acta neurochirurgica. 11/2009; 151(11):1505-9.

• Image-guided resection of small lesions in the cavernous sinus and Meckel's cave.

  Authors: M Nakamura, J K Krauss

  European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology. 08/2009;

  OBJECTIVE: The microsurgical resection of tumors or vascular lesions in the cavernous sinus and the neighbouring Meckel's cave has been considered as hazardous because of often associated cranialOBJECTIVE: The microsurgical resection of tumors or vascular lesions in the cavernous sinus and the neighbouring Meckel's cave has been considered as hazardous because of often associated cranial nerve morbidity. Despite increasing consent that many of such tumors should not undergo surgical therapy, the cavernous sinus and Meckel's cave may harbour small lesions of various origin, which are amenable for surgical resection. Surgery in this anatomical area needs a well directed approach. In this setting, neuronavigational guidance may provide a useful tool. We report on a series of patients operated on and guided by neuronavigation. METHODS: Five patients underwent a pterional approach for microsurgical resection. The procedures were planned and assisted by a pointer based neuronavigation system (Medtronic Stealth Station). Pathological entities included schwannoma, epidermoid, cavernoma and capillary hemangioma. Three lesions were located in the Meckel's cave and two lesions in the cavernous sinus. RESULTS: Intraoperative guidance by neuronavigation appeared to be particularly instrumental in identification of the appropriate site of dural incision over the target region for microsurgical resection. Except of a mild increase of facial hypesthesia in one patient, there were no new cranial nerve deficits. In three patients, preoperative symptoms improved immediately after surgery. CONCLUSION: The surgical resection of small tumors or vascular lesions within the Meckel's cave or cavernous sinus is facilitated by neuronavigational guidance with sufficient intraoperative reliability and safety. In consideration of well known anatomical landmarks, targeted entry into the cavernous sinus or Meckel's cave directed by neuronavigation enables a tailored approach for microsurgical resection.

• Neuronavigational guidance in craniofacial approaches for large (para)nasal tumors involving the anterior skull base and upper clival lesions.

  Authors: M Nakamura, T Stöver, T Rodt, O Majdani, M Lorenz, T Lenarz, J K Krauss

  European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology. 01/2009;

  OBJECTIVE: Due to the destruction of osseous landmarks of the skull base or paranasal sinuses, the anatomical orientation during surgery of frontobasal or clival tumors with (para)nasal extension isOBJECTIVE: Due to the destruction of osseous landmarks of the skull base or paranasal sinuses, the anatomical orientation during surgery of frontobasal or clival tumors with (para)nasal extension is often challenging. In this relation computer assisted surgical (CAS) guidance might be a useful tool. Here, we explored the use of CAS in an interdisciplinary setting. METHODS: The surgical series consists of 13 patients who underwent a lateral rhinotomy combined with a subfrontal craniotomy in case of significant intracranial tumor extension. The procedures were planned and assisted by advanced CAS techniques with image fusion of CT and MRI. Tumors included carcinomas (one case associated with an olfactory groove meningioma), esthesioneuroblastoma, chordoma, chondrosarcoma and ganglioglioma. RESULTS: The application of CAS in the combined approaches was both safe and reliable for delineation of tumors and identification of vital structures hidden or encased by the tumors. There was no perioperative 30-day mortality; however two patients died 5 weeks and 5 months after craniofacial tumor resection due to worsening medical conditions. The most common perioperative morbidity was postoperative wound complication in two cases. Tumors were either removed completely, or subtotal resection was achieved allowing targeted postoperative radiotherapy. CONCLUSION: Craniofacial approaches with intraoperative neuronavigational guidance in a multidisciplinary setting allow safe resection of large tumors of the upper clivus and the paranasal sinuses involving the anterior skull base. Complex skull base surgery with the involvement of bony structures appears to be an ideal field for advanced navigation techniques given the lack of intraoperative shift of relevant structures.

• Health-related quality of life in segmental dystonia is improved by bilateral pallidal stimulation.

  Authors: C Blahak, J C Wöhrle, H-H Capelle, H Bäzner, E Grips, R Weigel, K Kekelia, J K Krauss

  Journal of neurology. 03/2008; 255(2):178-82.

  In contrast to generalized dystonia, reports on the effectiveness of pallidal stimulation on quality of life in patients with segmental dystonia are sparse to date. In ten patients with idiopathicIn contrast to generalized dystonia, reports on the effectiveness of pallidal stimulation on quality of life in patients with segmental dystonia are sparse to date. In ten patients with idiopathic segmental dystonia we prospectively evaluated the effect of pallidal stimulation on quality of life using the SF-36 questionnaire. Parallel to the improvement of motor scores, total SF-36 scores and physical and mental health subscores improved significantly at follow-up to a mean of 17 months postoperatively. Thus, pallidal stimulation should be recognized as a promising treatment option in patients with segmental dystonia.

• Patterns of reoccurrence of segmental dystonia after discontinuation of deep brain stimulation.

  Authors: E Grips, C Blahak, H-H Capelle, H Bäzner, R Weigel, O Sedlaczek, J K Krauss, J C Wöhrle

  Journal of neurology, neurosurgery, and psychiatry. 04/2007; 78(3):318-20.

  The pattern of reoccurrence of symptoms after discontinuation of deep brain stimulation (DBS) has not been systematically studied in dystonia. Eight patients (mean age (SD) 53.8 (14.4) years) withThe pattern of reoccurrence of symptoms after discontinuation of deep brain stimulation (DBS) has not been systematically studied in dystonia. Eight patients (mean age (SD) 53.8 (14.4) years) with segmental dystonia at a mean follow-up of 11.3 (4.2) months were studied after implantation of bilateral DBS electrodes in the internal globus pallidus using a standard video protocol and clinical rating scales, immediately and at 2 and 4 h after switching off DBS. Dystonic signs returned sequentially, with a rapid worsening of phasic and a slower worsening of tonic dystonic components. In all patients, phasic dystonic features appeared within a few minutes, whereas the tonic elements of dystonia reoccurred with a more variable delay. Differential clinical effects when withdrawing DBS might reflect its influence on different pathophysiological mechanisms in dystonia.

• [Parapharyngeal abscess and osteomyelitic destruction of the odontoid process]

  Authors: K M Willenborg, T Stöver, H Becker, J K Krauss, T Lenarz

  Laryngo- rhino- otologie. 03/2007; 86(2):128-30.

  We report the case of a 55 year old man with osteomyelitic destruction of the odontoid process and a parapharyngeal abscess. The patient was admitted with diagnosis of meningitis and degenerativeWe report the case of a 55 year old man with osteomyelitic destruction of the odontoid process and a parapharyngeal abscess. The patient was admitted with diagnosis of meningitis and degenerative cervical spine disease without compression of spinal cord or nerve roots but progressive impairment of cervical spine mobility. Inflammatory parameters in serum and cerebrospinal fluid were detected and antibiotic therapy was initiated resulting in subjective improvement of symptoms. When impairment of cervical spine motility persisted and gait disturbance developed, a parapharyngeal abscess and an osteomyelitic destruction of the odontoid process caused by infection with staphylococcus aureus was diagnosed. After cleavage of the abscess and four months of antibiotic therapy the gait disturbance disappeared and mild impairment of cervical spine motility persisted.

• Deep brain stimulation for treatment of cervical dystonia.

  Authors: J K Krauss

  Acta neurochirurgica. Supplement. 02/2007; 97(Pt 2):201-5.

  Pallidal deep brain stimulation is an efficient treatment option in those patients with cervical dystonia who do not benefit from conservative treatment including local botulinum toxin injections.Pallidal deep brain stimulation is an efficient treatment option in those patients with cervical dystonia who do not benefit from conservative treatment including local botulinum toxin injections. Given the fact that other surgical treatment options such as selective peripheral denervation are available, it may be considered third-line treatment in most instances. Chronic bilateral pallidal stimulation improves dystonic posture and movements, pain caused by dystonia and disability related to dystonia. Preliminary data on longterm follow-up confirm its beneficial effect in the majority of patients. Given the frequency of cervical dystonia, pallidal deep brain stimulation will play a major role in the future.

• Chronic spinal cord stimulation in medically intractable orthostatic tremor.

  Authors: J K Krauss, R Weigel, C Blahak, H Bäzner, H-H Capelle, E Grips, M Rittmann, J C Wöhrle

  Journal of neurology, neurosurgery, and psychiatry. 10/2006; 77(9):1013-6.

  BACKGROUND: Orthostatic tremor with its sense of unsteadiness when standing may have a devastating effect on affected persons. Currently, there are no other treatment options in those who do notBACKGROUND: Orthostatic tremor with its sense of unsteadiness when standing may have a devastating effect on affected persons. Currently, there are no other treatment options in those who do not respond or who do not tolerate medical treatment. OBJECTIVES: To report on a pilot study on spinal cord stimulation in medically intractable orthostatic tremor. METHODS: Chronic spinal cord stimulation (SCS) was performed in two patients with medically-intractable orthostatic tremor via quadripolar plate electrodes implanted at the lower thoracic spine. The electrodes were connected to implantable pulse generators. RESULTS: Subjective and objective improvement of unsteadiness was achieved within a frequency range of 50 to 150 Hz, and occurred in the presence of stimulation-induced paraesthesia. With optimized stimulation settings polygraphic electromyelogram (EMG) recordings continued to show the typical 14-16 Hz EMG activity. The beneficial effect of SCS was maintained at long-term follow-up. CONCLUSIONS: The results of this pilot study indicate that SCS may be an option in patients with otherwise intractable orthostatic tremor.

• Evaluation of surface and volume rendering in 3D-CT of facial fractures.

  Authors: T Rodt, S O Bartling, J E Zajaczek, M A Vafa, T Kapapa, O Majdani, J K Krauss, M Zumkeller, H Matthies, H Becker, J Kaminsky

  Dento maxillo facial radiology. 08/2006; 35(4):227-31.

  OBJECTIVES: Three-dimensional computed tomography (3D-CT) of facial fractures has been reported as beneficial using surface (SR) and volume rendering (VR). There are controversial statementsOBJECTIVES: Three-dimensional computed tomography (3D-CT) of facial fractures has been reported as beneficial using surface (SR) and volume rendering (VR). There are controversial statements concerning the preferable algorithm. The purpose of this study was to evaluate and compare SR and VR for clinical 3D-CT in facial fractures on an experimental basis. METHODS: Multislice CT was obtained in 22 patients with facial fractures using two data acquisition protocols. Five SR and VR post-processing protocols were applied. Five assessors independently evaluated the quality of visualization of the fracture gap and dislocated fragments as well as the overall image quality using a five-point rating scale. The potential benefit of the 3D-images for radiological diagnosis and presentation was evaluated. The influence of the data acquisition protocol was analysed. RESULTS: SR in general achieved better evaluation scores than VR at corresponding thresholds. Variation of evaluation scores for all criteria was found for SR and VR depending on the segmentation threshold. Apart from the overall image quality no significant influence of the data acquisition technique was found for the evaluated criteria. CONCLUSIONS: SR provided sufficient and time efficient means for 3D-visualization of facial fractures in this study. No diagnostic benefit of VR over SR was found.

• Oscillatory pallidal local field potential activity correlates with involuntary EMG in dystonia.

  Authors: C C Chen, A A Kühn, K T Hoffmann, A Kupsch, G H Schneider, T Trottenberg, J K Krauss, J C Wöhrle, E. Bardinet, J Yelnik, P Brown

  Neurology. 03/2006; 66(3):418-20.

  The pathophysiology of dystonia is unclear. The authors recorded local field potentials (LFPs) from deep brain stimulation electrodes implanted in the pallidum of 13 dystonic patients. LFP powerThe pathophysiology of dystonia is unclear. The authors recorded local field potentials (LFPs) from deep brain stimulation electrodes implanted in the pallidum of 13 dystonic patients. LFP power correlated with the level of dystonic EMG in the sternocleidomastoid, with maximal positive correlations at the lower contacts of pallidal electrodes. The data suggest that the neuronal synchronization indexed by LFP oscillations in the globus pallidus may be mechanistically linked to dystonic EMG activity.

• Normal pressure hydrocephalus: survey on contemporary diagnostic algorithms and therapeutic decision-making in clinical practice.

  Authors: J K Krauss, B Halve

  Acta neurochirurgica. 05/2004; 146(4):379-88; discussion 388.

  BACKGROUND: There is no agreement on the best diagnostic criteria for selecting patients with normal pressure hydrocephalus (NPH) for CSF shunting. The primary objective of the present study was toBACKGROUND: There is no agreement on the best diagnostic criteria for selecting patients with normal pressure hydrocephalus (NPH) for CSF shunting. The primary objective of the present study was to provide a contemporary survey on diagnostic algorithms and therapeutic decision-making in clinical practice. The secondary objective was to estimate the incidence of NPH. METHOD: Standardized questionnaires with sections on the incidence of NPH and the frequency of shunting, evaluation of clinical symptoms, and signs, diagnostic studies, therapeutic decision-making and operative techniques, postoperative outcome and complications, and the profiles of different centers, were sent to 82 neurosurgical centers in Germany known to participate in the care of patients with NPH. FINDINGS: Data were analyzed from 49 of 53 centers which responded to the survey (65%). The estimated annual incidence of NPH was 1.8 cases/100.000 inhabitants. Gait disturbance was defined as the most important sign of NPH (61%). There was a wide variety in the choice of diagnostic tests. Cisternography was performed routinely only in single centers. Diagnostic CSF removal was used with varying frequency by all centers except one, but the amount of CSF removed by lumbar puncture differed markedly between centers. There was poor agreement on criteria for evaluation of continuous intracranial pressure recordings regarding both the amplitude and the relative frequency of B-waves. Both periventricular and deep white matter lesions were present in about 50% of patients being shunted, indicating that vascular comorbidity in NPH patients has gained more acceptance. Programmable shunts were used by more than half of the centers, and newer valve types such as gravitational valves have become more popular. CONCLUSIONS: According to the present survey, new diagnostic and therapeutic concepts on NPH have penetrated daily routine to a certain extent. Wide variability, however, still exists among different neurosurgical centers.

• Concepts of neurosurgical management of chronic subdural haematoma: historical perspectives.

  Authors: R Weigel, J K Krauss, P Schmiedek

  British journal of neurosurgery. 03/2004; 18(1):8-18.

  The history of chronic subdural haematoma (CSH), spanning from its possibly earliest beginnings throughout the centuries until the early 1980s, was investigated within the context of four differentThe history of chronic subdural haematoma (CSH), spanning from its possibly earliest beginnings throughout the centuries until the early 1980s, was investigated within the context of four different epochs. In the 'era of uncertainty', successful trephination, the modem method of choice for the treatment of CSH, was developed by neolithic men. Various historical sources indicate that patients with CSH might have undergone surgery at that time. CSH might have been one of the ailments that had spectacular courses of salvation after trephination. The entity of CSH was first described in the 'era of pioneers' in the seventeenth century by Johann Jacob Wepfer. The misconception of 'pachymeningitis hemorrhagica interna' was introduced by Rudolf Virchow in 1857. By the end of the nineteenth century it became more widely accepted that trauma was a possible cause of CSH. Successful neurosurgical treatment of CSH was first reported by Hulke in 1883. Putnam and Cushing, in 1925, focused on surgery as the treatment of choice for CSH. In the 'era of diagnostic refinement', the introduction of pneumencephalography and angiography allowed the diagnosis of CSH much earlier. Subsequently, the typical signs and symptoms of patients suffering from CSH changed from apathy and coma to headaches and discrete focal neurological symptoms. In the 'era of surgical routine', neurosurgical approaches became smaller and less invasive. Removal of the haematoma was identified as the primary goal of surgery. The use of closed system drainage markedly improved reexpansion of the brain after surgery. Burr hole craniostomy and twist drill craniostomy became the surgical treatment of first choice because of their low morbidity and mortality. There is growing evidence, however, that the neurosurgical learning curve has reached a plateau.

• Risperidone-responsive segmental dystonia and pallidal deep brain stimulation.

  Authors: J C Wöhrle, R Weigel, E Grips, C Blahak, H-H Capelle, J K Krauss

  Neurology. 09/2003; 61(4):546-8.

  A 67-year-old man with risperidone-responsive segmental dystonia underwent bilateral deep brain stimulation (DBS) of the globus pallidus internus. Prospectively, the authors assessed theA 67-year-old man with risperidone-responsive segmental dystonia underwent bilateral deep brain stimulation (DBS) of the globus pallidus internus. Prospectively, the authors assessed the Burke-Fahn-Marsden Dystonia Rating Scale in medication (M) and stimulation (S) "on"/"off" states. With DBS at 9 months, the score improved by 86% to 8.5 in M-"on"/S-"on" and 12.5 in M-"off"/S-"on." Studies of the effects of DBS and concomitant medication may be warranted in selected patients treated by DBS for dystonia.

• Outcome of contemporary surgery for chronic subdural haematoma: evidence based review.

  Authors: R Weigel, P Schmiedek, J K Krauss

  Journal of neurology, neurosurgery, and psychiatry. 08/2003; 74(7):937-43.

  OBJECTIVE: To evaluate the results of surgical treatment options for chronic subdural haematoma in contemporary neurosurgery according to evidence based criteria. METHODS: A review based on a MedlineOBJECTIVE: To evaluate the results of surgical treatment options for chronic subdural haematoma in contemporary neurosurgery according to evidence based criteria. METHODS: A review based on a Medline search from 1981 to October 2001 using the phrases "subdural haematoma" and "subdural haematoma AND chronic". Articles selected for evaluation had at least 10 patients and less than 10% of patients were lost to follow up. The articles were classified by three classes of evidence according to criteria of the American Academy of Neurology. Strength of recommendation for different treatment options was derived from the resulting degrees of certainty. RESULTS: 48 publications were reviewed. There was no article that provided class I evidence. Six articles met criteria for class II evidence and the remainder provided class III evidence. Evaluation of the results showed that twist drill and burr hole craniostomy are safer than craniotomy; burr hole craniostomy and craniotomy are the most effective procedures; and burr hole craniostomy has the best cure to complication ratio (type C recommendation). Irrigation lowers the risk of recurrence in twist drill craniostomy and does not increase the risk of infection (type C recommendation). Drainage reduces the risk of recurrence in burr hole craniostomy, and a frontal position of the drain reduces the risk of recurrence (type B recommendation). Drainage reduces the risk of recurrence in twist drill craniostomy, and the use of a drain does not increase the risk of infection (type C recommendation). Burr hole craniostomy appears to be more effective in treating recurrent haematomas than twist drill craniostomy, and craniotomy should be considered the treatment of last choice for recurrences (type C recommendation). CONCLUSIONS: The three principal techniques-twist drill craniostomy, burr hole craniostomy, and craniotomy-used in contemporary neurosurgery for chronic subdural haematoma have different profiles for morbidity, mortality, recurrence rate, and cure rate. Twist drill and burr hole craniostomy can be considered first tier treatment, while craniotomy may be used as second tier treatment. A cumulative summary of data shows that, overall, the postoperative outcome of chronic subdural haematoma has not improved substantially over the past 20 years.

• Polyethylene sheath device to reduce tumor cell seeding along the needle tract in percutaneous biopsy.

  Authors: J Woitzik, J K Krauss

  Surgical endoscopy. 03/2003; 17(2):311-4.

  BACKGROUND: Minimally invasive techniques such as percutaneous biopsy of suspected malignancies are used widely. Besides bleeding, tumor cell seeding along the needle or instrument tract is ofBACKGROUND: Minimally invasive techniques such as percutaneous biopsy of suspected malignancies are used widely. Besides bleeding, tumor cell seeding along the needle or instrument tract is of concern. METHODS: We have developed a polyethylene-sheath device (PSD) to reduce the risk of cell spread when withdrawing a biopsy instrument. The mechanism was tested for its feasibility with a model taking biopsies from lamb liver presoaked with fluorescein dye underneath a specimen of lamb muscle. RESULTS: Fluorescence microscopic examination did not demonstrate fluorescent dye along the needle tract when the PSD was used, whereas there was marked staining in controls. The PSD was intact after having been used to perform the biopsies. CONCLUSIONS: The PSD reduces the risk of cell spread along instrument tracts.