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Publications (7)11.53 Total impact

  • Jörg Klekamp
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    ABSTRACT: Basilar invagination is a rare craniocervical malformation which may lead to neurological deficits related to compression of brainstem and upper cervical cord as well as instability of the craniocervical junction. This study presents results of a treatment algorithm developed over a 20-year period focussing on anatomical findings, short-term and long-term outcomes.
    06/2014;
  • Jörg Klekamp
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    ABSTRACT: Object Surgery of intramedullary tumors is established as the treatment of choice for these challenging lesions. This study presents a detailed analysis of risk factors for surgical morbidity and data on long-term results for intramedullary tumors. Methods Among 1317 patients with tumors of the spinal canal treated between 1980 and 2012, 278 patients with intramedullary tumors are presented. A total of 225 of these patients underwent 246 operations for treatment of 250 tumors. The mean patient age was 41 ± 17 years (range 3 weeks to 83 years). Patients underwent follow-up through outpatient visits and questionnaires with a mean follow-up of 41 ± 53 months. Tumors were subdivided into 3 groups: displacing tumors (Type A, n = 162), infiltrating tumors (Type B, n = 80), and nonproliferating tumors (Type C, n = 8). A gross-total resection (GTR) was attempted for every tumor except for Type C lipomas. Participating surgeons were divided into 3 groups according to the number of operations they performed. Short-term results were determined for individual symptoms and the modified McCormick Scale, whereas tumor recurrence rates were calculated with Kaplan-Meier statistics. Results Overall, 83.3% of Type A tumors underwent GTR compared with 22.5% of Type B and none in Type C. Gross-total resection rates increased throughout the study period and correlated significantly with surgical experience. A worsened neurological state after surgery was seen in 61% of patients. This deterioration was transient in 41.5% and was a common observation after GTR. Permanent morbidity (19.5%) was lowest after GTR and correlated significantly with surgical experience and the preoperative neurological state. Further analysis showed that patients with tumors of thoracic levels, tumor hemorrhages, and malignant and recurrent tumors were at a higher risk for permanent morbidity. In the long term, tumor recurrence rates for ependymomas and benign astrocytomas correlated significantly with the amount of resection. Long-term morbidity affected 3.7% with a postoperative myelopathy related to cord tethering at the level of surgery and 21.9% in form of neuropathic pain syndromes. The rate of postsurgical cord tethering could be lowered significantly by using pia sutures after tumor resection. Neuropathic pain syndromes were more common after surgery for tumors with associated syringomyelia or those located in the cervical cord. Conclusions Intramedullary tumors should be surgically treated as soon as neurological symptoms appear. Gross-total resection is possible for the majority of benign pathologies. Cervical tumors are associated with higher GTR and lower permanent morbidity rates compared with thoracic tumors. Surgery on intramedullary tumors should be performed by neurosurgeons who deal with these lesions on a regular basis as considerable experience is required to achieve high GTR rates and to limit rates of permanent morbidity.
    Journal of neurosurgery. Spine 05/2013; · 1.61 Impact Factor
  • Jörg Klekamp
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    ABSTRACT: BACKGROUND:: Disturbances of cerebrospinal fluid (CSF) flow are the commonest cause of syringomyelia. Spinal arachnopathies may lead to CSF flow obstructions but are difficult to diagnose. Consequently, associated syringomyelias are often categorized as idiopathic. OBJECTIVE:: In this observational study on non-traumatic arachnopathies from 1991 to 2011, diagnosis of and long-term outcomes for these patients are presented and analyzed. METHODS:: 288 patients were evaluated (mean age: 47±15 years, follow-up: 54±46 months). Decompression with arachnolysis, untethering and duraplasty for restoration of CSF flow was recommended to patients with neurological progression. Neurological examinations, magnetic resonance images (MRI) and follow-up data were evaluated. Individual symptoms were analyzed during the first postoperative year, and long-term outcomes were analyzed with Kaplan-Meier statistics to determine rates for progression-free survival. RESULTS:: 189 patients either refused an operation or were managed conservatively for lack of progression. Among 79 unoperated patients with follow-up information available for up to 8 years, 2 patients deteriorated. 99 patients with progressive symptoms underwent 116 operations with 108 decompressions and 8 other surgeries. Three months postoperatively, 53% considered their status improved and 37% unchanged. In the long-term, surgery on arachnopathies limited to 2 spinal segments was followed by progression-free survival for 78% over 10 years, in contrast to 31% with extensive arachnopathies. CONCLUSION:: Surgery on non-traumatic arachnopathies related to syringomyelia should be reserved for patients with progressive symptoms. Arachnolysis, untethering and duraplasty provide good long-term results for focal arachnopathies. For extensive pathologies with a history of subarachnoid hemorrhage or meningitis, treatment remains a major challenge.
    Neurosurgery 11/2012; · 2.53 Impact Factor
  • Jörg Klekamp
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    ABSTRACT: Object Decompression of the foramen magnum is widely accepted as the procedure of choice for patients with Chiari malformation Type I (CM-I). This study was undertaken to determine the mechanisms responsible for neurological deterioration after foramen magnum decompression and the results of secondary interventions. Methods Between 1987 and 2010, 559 patients with CM-I presented, 107 of whom had already undergone a foramen magnum decompression, which included a syrinx shunt in 27 patients. Forty patients who were neurologically stable did not undergo another operation. Sixty-seven patients with progressive symptoms received a recommendation for surgery, which was refused by 16 patients, while 51 patients underwent a total of 61 secondary operations. Hospital and outpatient records, radiographic studies, and intraoperative images were analyzed. Additional follow-up information was obtained by telephone calls and questionnaires. Short-term results were determined after 3 and 12 months, and long-term outcomes were evaluated using Kaplan-Meier statistics. Results Sixty-one secondary operations were performed after a foramen magnum decompression. Of these 61 operations, 15 involved spinal pathologies not related to the foramen magnum (spinal group), while 46 operations were required for a foramen magnum issue (foramen magnum group). Except for occipital pain and swallowing disturbances, the clinical course was comparable in both groups. In the spinal group, 5 syrinx shunt catheters were removed because of nerve root irritations or spinal cord tethering. Eight patients underwent a total of 10 operations on their cervical spine for radiculopathies or a myelopathy. No permanent surgical morbidity occurred in this group. In the foramen magnum group, 1 patient required a ventriculoperitoneal shunt for hydrocephalus 7 months after decompression. The remaining 45 secondary interventions were foramen magnum revisions, of which 10 were combined with craniocervical fusion. Intraoperatively, arachnoid scarring with obstruction of the foramen of Magendie was the most common finding. Complication rates for foramen magnum revisions were similar to first decompressions, whereas permanent surgical morbidity was higher at 8.9%. Postoperative clinical improvements were marginal in both surgical groups. With the exception of 1 patient who underwent syrinx catheter removal and had a history of postoperative meningitis, all patients in the spinal group were able to be stabilized neurologically. Long-term results in the foramen magnum group revealed clinical stabilizations in 66% for at least 5 years. Conclusions Neurological deterioration in patients after a foramen magnum decompression for CM-I may be related to new spinal pathologies, craniocervical instability, or recurrent CSF flow obstruction at the foramen magnum. Whereas surgery for spinal pathologies is regularly followed by clinical stabilization, the rate of long-term success for foramen magnum revisions was limited to 66% for 5 years due to severe arachnoid scarring in a significant proportion of these patients. Therefore, foramen magnum revisions should be restricted to patients with progressive symptoms.
    Journal of Neurosurgery Pediatrics 10/2012; · 1.63 Impact Factor
  • Jörg Klekamp
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    ABSTRACT: This paper presents results of a prospective study for patients undergoing surgery for posttraumatic syringomyelia between 1991 and 2010. A group of 137 patients with posttraumatic syringomyelia were evaluated (mean age 45 ± 13 years, mean follow-up 51 ± 51 months) with pre- and postoperative MRI and clinical examinations presenting in this period and followed prospectively by outpatient visits and questionnaires. Surgery was recommended for symptomatic patients with a progressive course. Short-term results were determined within 3 months of surgery, whereas long-term outcomes in terms of clinical recurrences were studied with Kaplan-Meier statistics. Three groups were distinguished according to the type of trauma: Group A, patients with spinal trauma but without cord injury (ASIA E, n = 37); Group B, patients with an incomplete cord injury (ASIA C or D, n = 55); and Group C, patients with complete loss of motor function or a complete cord injury (ASIA A or B, n = 45). Overall, 61 patients with progressive symptoms underwent 71 operations. Of these operations, 61 consisted of arachnolysis, untethering, and duraplasty at the trauma level (that is, decompression), while 4 ASIA A patients underwent a cordectomy. The remaining procedures consisted of placement of a thecoperitoneal shunt, 2 opiate pump placements, and 2 anterior and 1 posterior cervical decompression and fusion. Seventy-six patients were not treated surgically due to lack of neurological progression or refusal of an operation. Neurological symptoms remained stable for 10 years in 84% of the patients for whom surgery was not recommended due to lack of neurological progression. In contrast, 60% of those who declined recommended surgery had neurological progression within 5 years. For patients presenting with neurological progression, outcome was better with decompression. Postoperatively, 61% demonstrated a reduction of syrinx size. Although neurological symptoms generally remained unchanged after surgery, 47% of affected patients reported a postoperative improvement of their pain syndrome. After 3 months, 51% considered their postoperative status improved and 41% considered it unchanged. In the long-term, favorable results were obtained for Groups A and C with rates for neurological deterioration of 6% and 14% after 5 years, respectively. In Group B, this rate was considerably higher at 39%, because arachnolysis and untethering to preserve residual cord function could not be fully achieved in all patients. Cordectomy led to neurological improvement and syrinx collapse in all 4 patients. The technique of decompression with arachnolysis, untethering, and duraplasty at the level of the underlying trauma provides good long-term results for patients with progressive neurological symptoms following ASIA A, B and E injuries. Treatment of patients with posttraumatic syringomyelia after spinal cord injuries with preserved motor functions (ASIA C and D) remains a major challenge. Future studies will have to establish whether thecoperitoneal shunts would be a superior alternative for this subgroup.
    Journal of neurosurgery. Spine 07/2012; 17(3):199-211. · 1.61 Impact Factor
  • Jörg Klekamp
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    ABSTRACT: Foramen magnum decompression is widely accepted as the treatment of choice for Chiari I malformation. However, important surgical details of the procedure are controversial. This study analyzes 371 decompressions focusing on intraoperative findings, analysis of complications, and long-term outcomes. Among 644 patients between 1985 and 2010, 359 patients underwent 371 decompressions. Surgery for symptomatic patients consisted of suboccipital craniectomy, C1 laminectomy, arachnoid dissection, and duraplasty. Short-term results were determined after 3 months; long-term outcomes were evaluated with Kaplan-Meier statistics. The mean age was 40 ± 16 years; mean follow-up was 49 ± 56 months; 75.8% demonstrated syringomyelia. The complication rate was 21.8% with permanent surgical morbidity of 3.2% and surgical mortality of 1.3%. Of the patients, 73.6% reported improvement after 3 months; 21% were unchanged. Overall, 14.3% demonstrated a neurological deterioration within 5 years and 15.4% within 10 years. The severity of neurological symptoms correlated with the grade of arachnoid pathology. Outcome data correlated with the number of previous decompressions, severity of arachnoid pathology, handling of the arachnoid, type of duraplasty, and surgical experience. First-time decompressions with arachnoid dissection and an alloplastic duraplasty resulted in surgical morbidity for 2.0%, a 0.9% mortality rate, postoperative improvement after 3 months for 82%, and neurological recurrence rates of 7% after 5 years and 8.7% after 10 years. Arachnoid pathology in Chiari I malformation has an impact on clinical symptoms and postoperative results. Decompressions with arachnoid dissection and an alloplastic duraplasty performed by surgeons experienced with this pathology offer a favorable long-term prognosis.
    Neurosurgery 05/2012; 71(2):365-80; discussion 380. · 2.53 Impact Factor
  • Jörg Klekamp
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    ABSTRACT: The treatment of tethered cord syndromes in adults is discussed regarding the natural history and surgical indications. The author analyzes data obtained in patients who were diagnosed with a tethered cord in adulthood and either underwent surgical or conservative therapy between 1991 and 2009. Since 1991, data obtained in 2515 patients with spinal cord pathologies were entered into the spinal cord database, and prospective follow-up was performed through outpatient visits and questionnaires. Of the 2515 patients, 85 adults with a tethered cord syndrome formed the basis of this study. The tethering effect was caused either by a split cord malformation, a thick filum terminale, a conus medullaris lipoma with extradural extension, or various combinations of these mechanisms. The mean age of the patients was 46 ± 13 years (range 23-74 years) and the mean follow-up duration was 61 ± 62 months. Two groups were distinguished based on the absence (Group A, 43 patients) or presence (Group B, 42 patients) of an associated lipoma or dysraphic cyst (that is, dermoid, epidermoid, or neurenteric cyst). Surgery was recommended for patients with symptoms only. Short-term results were determined within 3 months of surgery, whereas long-term outcomes (clinical recurrences) were evaluated using Kaplan-Meier statistics. For all patients, pain was the most common major complaint. Severe neurological deficits were rare. In Group A, 20 of 43 patients underwent surgery, whereas in Group B 23 of 42 patients underwent surgery. Among individuals who did not undergo surgery, 17 patients refused surgery and 25 patients underwent recommended conservative treatment. Short-term postoperative results indicated a significant improvement of pain and a stabilization of neurological symptoms. Long-term results showed a good prognosis in patients in whom first-time (that is, nonrevision) surgery achieved successful untethering, with a 10-year rate of neurological stabilization in 89% of Group A and a 10-year rate of neurological stabilization in 81% of Group B patients. The benefit of secondary operations in Group B was limited, with eventual clinical deterioration occurring in all patients within 10 years. For patients treated conservatively, follow-up information could be obtained in 33 of 42 patients. Twenty-eight patients remained in stable clinical condition. Only 5 of the conservatively treated patients experienced clinical deterioration over time; in 4 of these individuals with deterioration, surgery had been recommended but was refused by the patient. The clinical recurrence rate in all conservatively treated patients was 21% after 10 years. With a recommendation for surgery this figure rose to 47% within 5 years. Surgery in adult patients with a tethered cord syndrome should be reserved for those with symptoms. In surgically treated patients, pain relief can often be achieved, and long-term neurological stabilization tends to persist more often than it does in conservatively treated patients. A conservative approach is warranted, however, in adult patients without neurological deficits. Revision surgery in patients with complex dysraphic lesions should be performed in exceptional cases only.
    Journal of neurosurgery. Spine 05/2011; 15(3):258-70. · 1.61 Impact Factor