Potential Areas for Gene Therapy in the Brain

The ''tenacious start'' of gene therapy for neurological diseases is not really surprising, since gene therapy to the brain faces unique obstacles in addition to those one faces with gene therapy in general. Evaluation of the appropriate vector, route of administration, efficiency of the transgene ex- pression, and immune response against gene transfer vectors being used are some of the problems one faces with gene therapy. In addition to those, gene therapy to the brain has to overcome...

Complications

Although indications, surgical technique and technological advances regarding ETV have been largely reported, the complications of the technique have been the subject of a surprisingly scarce interest (Teo et al. 1996, Schroeder et al. 2002). Furthermore, only a few papers discuss the quality of the complications in term of cost-effectiveness among ETV and traditional treatments (Garton et al. 2002, Richard et al. 2000). Such a phenomenon depends on the low rate of complications itself but also...

The Hybrid Lateral Superior Approach

Nasociliary Nerve

This hybrid approach involves the roof and the lateral wall of the orbit. It was, in effect, first envisaged by Karagjozov 21 when he extended the superior approach to encroach into the lateral wall and then other surgeons operated using the same route with some minor modifications 1 . As with the superior route it could be based on either a double flap or a single flap encroaching on the edge of the orbit. Single-flap methods are difficult to perform and the dura mater cannot be under control....

Aetiologies

Neurofibromas Treatment

Aetiologies pertaining to orbital tumours are great in number, and often necessitate entirely different procedures. In order to avoid proposing surgery that may be, on occasions, useless (for example, rhabdomyosarcoma in children), or, inversely, to avoid deferring surgery that is imperative (in the event of orbital meningioma), it is necessary to detail the clinical and para-clinical characteristics of the principal aetiologies which relate to tumours. Adult and paediatric varieties of OTs...

Introduction

Back pain is the most common cause of activity limitation in adults younger than 45 years, the second most frequent reason for visits to the physician, the fifth ranking cause of admission to hospital and the third most common cause of surgical procedures (Van Tulder et al., 2002). A letter to the British Medical Journal in October 2003, Dr Lina Talbot reported ''Every general practitioner has one - a patient who has had back surgery but hasn't improved''. Around 20000 cases of failed back...

The Superior Approach Route

Nasociliary Cadaver

Use of the frontal route to access the orbit was systematically employed by Dandy 14 and Naffziger 30 . This approach was then used by other surgeons as reported in a number of articles. More recently, use of this route has become more widespread as a result of the work of Bachs 4 (a single flap technique) and Karagjozow 21 (a double flap technique). Both of these techniques afford excellent exposure but they are difficult to perform and take a long time. In practice, in the Bach's operation 4...

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Aescolapse Tuttlingen Germany

Elements of the Decq endoscope (image courtesy of Karl Storz GmbH & Co., Tuttlingen, Germany). When used with a holder, two hands work is possible through the two symmetric working channels (image courtesy of Dr. Philippe Decq, Hopital Fig. 10. Elements of the Decq endoscope (image courtesy of Karl Storz GmbH & Co., Tuttlingen, Germany). When used with a holder, two hands work is possible through the two symmetric working channels (image courtesy of Dr. Philippe Decq, Hopital...

Scavidin Mountain

Dietrich HH and Dacey RG (2000) Molecular keys to the problems of cerebral vasospasm. Neurosurgery 46(3) 517-29 Durin MJ et al (2003) Development and optimization of adeno-associated virus vector transfer into the central nervous system. Methods Mol Med 76 221-236 During MJ et al (1994) Long-term behavioral recovery in parkinsonian rats by an HSV vector expressing tyrosine hydroxylase. Science 266 1399-403 Eberhardt O, Schulz JB (2004) Gene therapy in Parkinson's disease. Cell Tissue Res 63(4)...

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Thoracolumbar Fascia Pain

Diagnostic and treatment algorithm for predominant or exclusive low back Fig. 2. Diagnostic and treatment algorithm for predominant or exclusive low back gery and are added to the pre-existing, unrelieved pain. In FBSS particularly, low back and leg pain can be present simultaneously. Investigations must be conducted according to the predominant feature (leg or back pain) bearing in mind that leg pain may be triggered by low back structures and even neuropathic-like pain may be due to...

Introduction Definition of Subject and Limitations

Surgical anatomy is not the same as that of anatomy books. However, even if the latter are essential to understand and carry out this surgery, they are not particularly pertinent in the domain of neurosurgery since access to the orbital cone, the nerve and the optic canal is strictly reserved to the domain of neurosurgery. This study is neither a thesaurus nor an exhaustive description of orbital tumours that presents all the questions that all specialists might ask. Therefore, in order to...

Abstract

Advances in surgical instrumentation and technique have lead to an extensive use of endoscopic third ventriculostomy in the management of pediatric hydrocephalus. The aim of this work was to point out the leading aspects related to this technique. After a review of the history, which is now almost one century last, the analysis of the endoscopic ventricular anatomy is aimed to detail normal findings and possible anatomic variations which might influence the correct conclusion of the procedure....

Minimally Invasive Treatments for Low Back Pain

Algorithm Treatment For Hydrocephalus

A diagnostic strategy properly conducted leads to specific treatment. For the predominant causes of back pain, treatment is available. When no diagnosis can be established, the treatment will be symptomatic and when all medical and conservative treatments have failed, minimally invasive approach including spinal cord stimulation and intrathecal drug delivery systems will be used. It is estimated that in a substantial percentage of patients with chronic back pain the lumbar disk is the pain...

Info

Gene Storz

1 Aesculap - Tuttlingen, Germany Wolf, Knittlingen, Germany. 2 Codman amp Shurtleff Johnson amp Johnson New Brunswick, NJ. 3 Karl Storz GmbH amp Co., Tuttlingen, Germany. W Working channel I A Irrigation Aspiration channel. 1 Aesculap - Tuttlingen, Germany Wolf, Knittlingen, Germany. 2 Codman amp Shurtleff Johnson amp Johnson New Brunswick, NJ. 3 Karl Storz GmbH amp Co., Tuttlingen, Germany. W Working channel I A Irrigation Aspiration channel. 1998 . The image formed by the objective lens is...

Challenges of Gene Therapy in the Brain

Gene Therapy Principle

As mentioned earlier, gene therapy to the brain faces unique difficulties in addition to the general issues one faces with gene therapy. A major limiting factor is the delivery of the gene to the brain. The brain is surrounded by the blood brain barrier BBB , which most gene expression vectors do not naturally cross. The BBB is a capillary barrier that results from a continuous layer of endothelial cells bound together with tight junctions. The endothelial barrier excludes molecules from the...

Conclusions

Neurosurgical approach of orbital tumours concern the posterior two thirds of the orbit. Whether concerning intra- or extra-conical pathologies, it is their direct or indirect repercussion on the optic nerve that, essentially justifies the neurosurgical indication. Any lesion that necessitates an intraoperative access to of the orbit, its contents and its peri-cerebral spaces should be approached by using one of the neurosurgical techniques that we have discussed. The current methods of...

References

Al-Mefty O, Fox JL 1985 Superolateral orbital exposure and reconstruction. Surg Neurol 23 609-613 2. Ammirati M, Spallone A, Ma J, Cheatham M, Becker D 1993 An anatomi-cosurgical study of the temporal branch of the facial nerve. Neurosurgery 33 1038-1044 3. Arai H, Sato K, Katsuta T, Rhoton AL Jr 1996 Lateral approach to intraorbital lesions anatomic and surgical considerations. Neurosurgery 39 11571162 4. Bachs A 1962 Contribucion al tratamento de la exoftalmia unilateral por lesiones...

Descriptive Anatomy of the Different Layers Covering the Cranium

Scalp Incision

A great deal of work has been carried out on the scalp 3, 8, 9, 12 . What follows is a description of the various layers as they appear on dissection. The scalp is made up of the skin, sub-cutaneous tissue and the galeal aponeurosis. The skin and subcutaneous tissue are extremely thick, representing one of the special features of the scalp. The vessels and nerves are found at the lower surface of the sub-cutaneous adipose tissue. The innermost border of this sheet is delineated by the...

Indications

A correct clinical indication is the most important factor influencing the success rate of ETV. Advances in MR imaging have improved the understanding of the specific physiopathologic mechanism at the base of the different forms of hydrocephalus consequently representing an essential adjunct for the correct patient selection. A more accurate preoperative diagnosis of mixed types of communicating hydrocephalus, where obstructive factors may still play a role, has lead to extend the indications...

Endoscopic Third Ventriculostomy in the Treatment of Hydrocephalus in Pediatric Patients

MAssimi1, P. SpennAto2, E. CiANciuLLi3, iPediatric Neurosurgical Unit, Catholic University Medical School, Rome, Italy 2Neuroendoscopy Unit, Department of Pediatric Neurosurgery, Santobono- Pausilipon Children's Hospital, Naples, Italy 3Department of Pediatric Neuroradiology, Santobono-Pausilipon Children's Historical Ventricular Preoperative Evaluation of Ventricular Neuroendoscopic Ventricular Anatomy of the Frontal Horn of the Lateral Ventricles and of the...

Analysis of Outcome

Nursing Management Icp

ETV, by forming a communication between the third ventricle and the subarachnoid spaces, restores an almost ''physiological'' CSF circulation in case of obstructive hydrocephalus. The recent views on the pathophysi-ology of hydrocephalus Greitz 2004 enhance the importance of the intra-cranial compliance, that is widely dependent on the free movement of the CSF between the cranial and the spinal subarachnoid spaces. Despite of the accuracy of patients selection, several reports show that in a...

Minimally Invasive Approaches Diagnostic Procedures for Low Back Pain

Discogram Approach

The precision diagnostic approach was developed to determine in conjunction with other diagnostic tools the cause or the causes of pain in low back pain. By stimulating or anesthetising specific structures, needle procedures can determine precisely the source of the patient's pain Steindler, 1938 . These procedures can target the source of pain and unlike imaging studies determine whether the structure is generating pain or not. This approach is subject to control in order to ensure the...

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Gaab Endoscope

Gaab miniature neuroscope autoclavable W Working channel I A Irrigation Aspiration channel. Lateral irrigation channel allows use of additional instruments with a diameter of 1 mm parallel to the instrument channel. W Working channel I A Irrigation Aspiration channel. Lateral irrigation channel allows use of additional instruments with a diameter of 1 mm parallel to the instrument channel. small foramen of Monro Table 3 . The absence of a rigid rod lens system allows a very wide working channel...

Surgical Approaches

Frontopterional

As a general rule, it is necessary to ask the question why, for orbital tumours an orbital approach is more readily practised in the domain of neurosurgery than in the domain of ophthalmology or plastic surgery. There appear to be two circumstances that justify this decision it is preferable to choose a neurosurgical approach in the case of lesions to the two posterior thirds of the orbit and or in the event that it is necessary to check the excision of the tumour as well as that of...

Innervation of the Scalp Figs 8 and

Frontotemporal Branch of the Facial Nerve The frontotemporal region is innervated by the superior or frontotemporal branch of the facial nerve. This branch leaves the parotid gland and Fig. 8. Dissection of a right facial nerve FN in a cadaver specimen. Note the relationships between the frontotemporal branch of the facial nerve FTB and the trunk of the superficial temporal artery STA Fig. 8. Dissection of a right facial nerve FN in a cadaver specimen. Note the relationships between the...

Historical Background

The increasing diffusion of endoscopy in the surgical practice is one of the most impressive results of the continuous search of methodologies aimed at decreasing patient's discomfort while maintaining a therapeutic efficacy comparable to that of traditional approaches requiring more invasive procedures. Its progressive wider use is supported by a constantly developing technology. Actually, endoscopic third-ventriculostomy ETV has become the routine treatment for obstructive hydrocephalus in...

Conclusion

Although today's young neurosurgeons have at their disposal sophisticated surgical neuronavigation tools, they nevertheless still need the basic anatomical knowledge which is indispensable to understanding and executing a classic cranial approach. Teaching how to make the exposure to create a perfect, centered bone flap needs to be kept as a priority in the surgical training of even the youngest surgeons. The basic anatomy described in this chapter is by no means exhaustive but it is intended...

Anatomy of the Orbit

Orbit Nerves

The orbits are two cavities located symmetrically on either side of the sagittal plane at the root of the nose. The shape of each is that of a four-sided pyramid with its axis set off from the sagittal plane by an angle of 20 . The roof is thin and concave in a downward direction. It can be separated into two laminae by the frontal sinus there is the lacrimal fossa in the anterolateral part, and the anteromedial part houses the fovea into which the trochlea of the superior oblique muscle is...

Identification of Surface Landmarks of the Skull

Petrous Carotid Exposure

The Base of the Skull Figs. 10 to 13 Rather than describing the classic features of the base of the skull, we have chosen to focus on the orientation of the head in space and the consequences of its position during the operation. How the base of the skull is positioned for a pterional approach or one via the posterior fossa is extremely important and is going to determine the outcome of the procedure. Fig. 10. Anatomical modifications after the patient's head has been rotated to the Fig. 10....

Algorithm for Diagnostic Assessment of Low Back Pain and FBSS

An algorithm to investigate low back pain must be based on the likelihood of the diagnosis. In 1995, Schwarzer et al. described the prevalence of the predominant aetiologies in low back pain. To investigate chronic back pain, minimally invasive tests have been developed during the last 15 years and there reproducibility and validity have been well documented Bog-duk, 2002 b . The quality of the test itself or the expertise of the physician performing the procedure is a necessary but not...

Ventricular Anatomy

Intraventricular Septations

A correct preoperative study of individual ventricular anatomy and the endoscopic recognition of ventricular structures is mandatory to increase the success rate of ETV and to decrease the percentage of operative complications. Anatomic anomalies and morphological variants of the cerebral ventricular system have been indeed extensively described, most of them in relation with the etiology of the hydrocephalus and the patient's age their potentially adverse effects on the surgical procedure have...

Vasculature of the Scalp Figs

Scalp Vasculature

The corrosion casting technique the various possibilities of which are thoroughly described by Hill in 1981 5 reveals the richness of the vascular network at the cephalic extremity. It gives a picture of the intracranial and extracranial arterial and venous tree because it removes both soft tissues and the cranium. Fig. 2. a and b The arteries and veins to and from the head Complete corrosion of the tissues leaves the cast of the intra and extracranial arterial and venous tree. Note the...

Minimally Invasive Treatments for Leg Pain

Therapeutic approaches to leg pain are closely related to their underlying mechanism. Leg pain arising for low back pathology can be either inflammatory, or neuropathic. Epidural steroid injection is probably the most frequent procedure performed to treat radicular pain. Technique is simple, and safe. Complications occur and may be related to the needle placement or to the drug administered. They include infections, dural tap and very rarely neurological damage Nelson et al., 2001 . Manchikanti...

Preface

As an addition to the European postgraduate training system for young neurosurgeons, we began to publish in 1974 this series of Advances and Technical Standards in Neurosurgery which was later sponsored by the European Association of Neurosurgical Societies. This series was first discussed in 1972 at a combined meeting of the Italian and German Neurosurgical Societies in Taormina, the founding fathers of the series being Jean Brihaye, Bernard Pertuiset, Fritz Loew and Hugo Krayenbuhl. Thus were...