2009, Vol 9, No 1
Back pains under examination in category diseases from the job processing
Aktualn Neurol 2009, 9 (1), p. 11-16
ABSTRACT

Back pains constitute a civilization-related disease and a true social calamity. Together with headaches, back pains represent the most common pain syndromes reported by patients to physicians of various specializations 60-90% of people experience a single episode of pain at least once in a lifetime. The scope of the study was to determine the frequency and types of back pains related to the performance of work in a hard coal mine. Material and methodology: The study included 417 employees and consisted in surveying, data collection, medical examinations and additional tests. The study was conducted in the work environment of a modern company, highly- mechanized, with good standing and job security. In view of this, it was assumed that the employees have equal standards of living and are not exposed to the impact of psychological and social factors on the incidence of back pains. The type and duration of the treatment was also considered in the study, as well as possible return of employees to the same work stand. Results: The frequency of the occurrence of back pains corresponds to the level of load on the spine, age and work experience in employees under 50, with 11-15 years of work experience, and then it falls. localized pain was found in 49.2% of the tested miners, stretch signs in 14%. In the younger miners group 83.6% work underground, and 76.3% perform works involving substantial load on the spine; in the older miners group it is only 5.4%. 3.4% of all tested miners changed their work-stand, and 0.6% took advantage of the disability benefits. Conclusions: The relation between the occurrence of back pains and age was confirmed. The relation between years of work experience in mining and increased prevalence of spinalgia was not documented. The determination of the ergonomics of the work-stand is required for further investigation of this relation. 

Keywords: back pains, miner, work-stand, physical work, lumbar-sacral spine section, overwork
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SYMPOSIUM: HYDROCEPHALUS. Surgical treatment of hydrocephalus with the use of neuroendoscopic techniques
Aktualn Neurol 2009, 9 (1), p. 17-25
ABSTRACT

The authors present a review of literature connected with treatment of hydrocephalus in children with a use of neuroendoscopic techniques. The history of neuroendoscopic procedures is divided into three, crucial for therapeutic reasons, periods: 1) pioneering stage, connected with the introduction of neuroendoscopic procedures in neurosurgery, which was characterized by a very high level of mortality and morbidity; 2) modern stage, when the whole technique of neuroendoscopic operative procedures were designed, after Hopkins discoveries; 3) contemporary stage, characterized by a refinement of neuroendoscopic equipment, virtual techniques, and decrease of morbidity and mortality level connected with neuroendoscopic procedures. Additionally, it could be found the description of basic neuroendoscopic equipment. The current qualification criteria for neuroendoscopic procedures are explained. Main neuroendoscopic procedures, which are used in operative treatment of hydrocephalus, are described in the paper. Regarding currently available neuroendoscopic equipment, neurosurgeons still have dissatisfying possibilities of haemostasis. That problem seriously limits a possibility of treatment hydrocephalus in a course of brain tumour with a use of neuroendoscopic treatment. Basing on literature and own experiences, the authors present clinical results and side effects of the operative treatment. The article is finished by future prospects for further development of neuroendoscopic procedures. 

Keywords: hydrocephalus, neuroendoscopic third ventriculostomy, aqueductoplasty, neuroendoscopic techniques, multicompartmental hydrocephalus
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SYMPOSIUM: HYDROCEPHALUS. Shunt systems in the treatment of hydrocephalus
Aktualn Neurol 2009, 9 (1), p. 26-36
ABSTRACT

The history of hydrocephalus treatment: The history of hydrocephalus operative treatment is very long, dating back to the times of Hippocrates (V century BC), who attempted to treat hydrocephalus by means of puncturing dilated cerebral ventricles. Along with general development of medicine, getting familiar with brain anatomy and physiology of cerebrospinal fluid circulation, and the development of new operational techniques in neurosurgery, a number of diverse hydrocephalus treatment methods had been introduced, but still it was a disease ending up with death or disability. A breakthrough moment, in which hydrocephalus treatment got revolutionized, was the day when a ventriculojugular shunt, with the use of a one-way flow stainless steel spring-ball valve, was first introduced in a six-month-old boy. Spitz and Nulsen reported this successful procedure in 1952. Since then, hydrocephalus treatment with the use of one-way shunt systems has become an approved and the most commonly used method of clinical management, which saves many patients’ lives, reduces their disabilities and lets them develop properly. The valve implantation made a huge progress in hydrocephalus treatment. However, shortly afterwards it turned out that these were imperfect systems leading to a variety of complications in patients. To date, in spite of a considerable progress in this field, a perfect valve has not been designed. Nowadays, the development of hydrocephalus surgical treatment takes two directions. The first is searching for an ideal valve, the other is improving neuroendoscopic techniques. Indications and contraindications for insertion of shunt systems: The valve implantation is indicated in the event of hydrocephalus diagnosis if: a) disease cause cannot be removed; b) there are no indications for endoscopic third ventriculostomy (ETV). Contraindications for the implantation of a valve are as follows: nervous system infections, bleeding to cerebral ventricles, severe systemic infections and skin infections. In order to reduce high intracranial pressure, a Rickham reservoir is initially implanted in infants or external ventricular drainage in older patients. Once cerebrospinal fluid is normalized and patient’s condition is stable, the valve can be implanted. Currently available shunts systems: Every shunt system is basically composed of three components: proximal catheter for access to cerebrospinal fluid (ventricular or lumbar), valve system, and distal catheter that diverts cerebrospinal fluid towards a drainage cavity (peritoneal or intracardiac). Most manufacturers offer a variety of shunt components and configurations. Available valve systems can be divided into four categories: 1) with respect to drain placement: a) ventriculoperitoneal shunt, b) ventriculoatrial shunt, c) lumboperitoneal shunt; 2) with respect to valvular mode of action: a) standard differential pressure valves, b) differential pressure valves with integral siphon-reducing devices, c) adjustable (programmable) valves, d) CSF flow-control valves; 3) with respect to valvular structure regulating flow: a) diaphragm valves, b) slit valves, c) miter valves, d) spring valves; 4) modifications and configurations of shunt system components. The choice of shunt systems: No unambiguous scientific criteria for the choice of the particular valve type exist. No such valve is obtainable, which could be better and effective than others. When one chooses a valve, he or she should make a precise clinical analysis of disease progression, focus on valve machinery and implantation method. Ventriculoperitoneal shunt insertion technique: Technically, it is a very easy procedure. However, it requires paying special attention because of possible numerous complications. The surgery should last as short as possible. Therefore, a sound knowledge of surgical techniques as well as shunt system construction and its working mechanism is required. Complications: Shunt complications can be categorized into three groups: 1) mechanical; 2) infectious; 3) functional failure. Postoperative care: Patient with valve transplant should be taken under neurosurgical, ophthalmological, and psychological care. We always try to inform our patients about symptoms of valve dysfunction. In order to determine if an implanted valve works well, we analyse patient’s clinical condition and ophthalmological, psychological, and imaging examination results. 

Keywords: hydrocephalus, surgical treatment, types of shunt systems, inserting a shunt, shunt complications
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SYMPOSIUM: HYDROCEPHALUS. Posthaemorrhagic hydrocephalus in neonates and infants
Aktualn Neurol 2009, 9 (1), p. 37-44
ABSTRACT

Intra- and periventricular haemorrhage (PVH) is one of the most common and serious complications of preterm birth. It may lead to the hydrocephalus and neurodevelopmental disability. The author present the up-to-date knowledge concerning following aspects of posthaemorrhagic hydrocephalus: epidemiology, pathophysiology, clinical symptoms, diagnostics, treatment options and prognosis. The possibilities of prevention of the PVH, also with the most recent method of intraventricular fibrinolytic therapy and drainage, were also discussed. The early management of posthaemorrhagic hydrocephalus in premature infants is very difficult and connected with many controversies. although various options of surgical treatment are available in these cases all of them have many disadvantages. Such surgical therapeutic measures like ventricular and lumbar tapping, external ventricular drainage, inserting a ventricular access device (e.g. Rickham reservoir), ventriculosubgaleal shunt and eventually implantation of ventriculoperitoneal shunt were discussed. The modern endoscopic procedures used in hydrocephalus (endoscopic third ventriculostomy and cauterization of arachnoid plexus) were also presented. 

Keywords: intraventricular haemorrhage, posthaemorrhagic hydrocephalus, neonates, prevention, treatment
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SYMPOSIUM: HYDROCEPHALUS. Hydrocephalus in children with brain tumours
Aktualn Neurol 2009, 9 (1), p. 45-51
ABSTRACT

Brain tumours comprise 20-25% of paediatric neoplasms and constitute the second most common group, after leukaemia. They are responsible for approximately 20% of cases of hydrocephalus in children. Mechanical compression of the ventricular system is the most frequent cause of hydrocephalus. Malabsorption or overproduction of cerebrospinal fluid are less commonly observed. Hydrocephalus most commonly affects children with intra-axial brain tumours. Benign tectal gliomas, tumours of the posterior part of the third ventricle (pineal region tumours) and cerebellar vermis and fourth ventricle tumours are the most concerned. Hydrocephalus accompanies also a relatively great number of tumours located in suprasellar region or within the brainstem. Surgical treatment of hydrocephalus depends on location of the tumour and patient’s clinical condition. Surgical resection of a large majority of hemispheric, intraventricular, suprasellar and cerebellar tumours results with withdrawal of hydrocephalus. The rest of the patients requires neuroendoscopic procedures (third ventriculostomy) or shunting. Neuroendoscopic procedures are performed in children with pineal tumours as a first treatment option. Patients with brainstem tumours are subjected to the third ventriculostomy or shunting. Children with severe clinical condition require external ventricular drainage or the third ventriculostomy before the resection of the tumour. Prognosis in children with hydrocephalus and brain tumour depends mainly on tumour’s type and further course of the primary disease. 

Keywords: children, shunting, neuroendoscopy, brain tumours, hydrocephalus
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Vitamins for “memory”
Aktualn Neurol 2009, 9 (1), p. 52-62
ABSTRACT

The vitamins are the exogenous, organic compounds with different structures, which play the important biological functions in our organisms, especially as the catalysts. To modulate the biochemical reactions the vitamins should be delivered in the appropriate quantities which are determined by health status and many exogenous factors as dietary habits, drugs etc. In the last years it can be noted the intensity in the studies on the role of the vitamins in neurological diseases. No other organ is such dependent on nutritional substances as the central nervous system. The mentioned diseases include these with unknown aetiology or these for which any effective therapy has not yet been found. The results of the taken studies described in this work surprisingly change approach to the vitamins. Some role of the vitamins was reported in the neurological diseases, such as atherosclerosis, dementia, including Alzheimer disease, epilepsy. It is worth of noting the role of the vitamins in aetiology and supportive therapy of neuropathies, Parkinson disease, post-transplantation headaches. In this article the results of the studies on the role of the vitamins in some serious neurological diseases with similar aetiology and symptoms, such as stroke atherosclerosis-related, dementia were presented. 

Keywords: vitamins, homocysteine, atherosclerosis, stroke, dementia
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Cognitive impairment in neoplastic disease and paraneoplastic neurological syndromes
Aktualn Neurol 2009, 9 (1), p. 67-71
ABSTRACT

Cognitive impairment constitutes important clinical problem in neoplastic diseases, especially in paraneoplastic neurological syndromes. Chemotherapy of breast and hormonotherapy of prostate cancers are the main causes of cognition dysfunction, connected directly with neoplasm. Clinical presentation is diverse and includes deterioration of concentration, memorizing, thinking, and verbal memory in breast cancer patients and impairment of concentration, memory, visuospatial abilities and executive functioning in prostate cancer ones. It is necessary to emphasize that the patients are at advanced age, with numerous comorbid conditions and suffer from advanced cancer. Moreover, usually patients manifest anxiety, dysphoria and depression induced by neoplasm diagnosis. All above-mentioned factors can influence on cognitive functions. Paraneoplastic neurological syndromes (PNS) are remote effects of cancer, not caused directly by invasion of the tumour or its metastases. Changes in cognition are caused by limbic encephalitis (LE) and paraneoplastic cerebellar degeneration (PCD). These paraneoplastic syndromes are usually associated with small cell lung cancer, thymoma, breast, ovarian, testis cancer and Hodgkin’s disease. Presentation of specific clinical symptoms and signs including memory loss, seizures and psychiatric symptoms, detection of paraneoplastic antibodies and abnormalities in neuroimaging examination help to establish the diagnosis. Paraneoplastic cerebellar degeneration includes clinical syndromes connected with different tumours and differing from each other in the course of disease and immunological reactions. The symptoms develop within weeks or months with cerebellar syndrome. Executive dysfunctions include planning, verbal fluency, working memory, abstract reasoning and set-shifting. Difficulties with orientation and visuospatial memory may also occur. Diagnosis, like in LE, is established when paraneoplastic antibodies are detected, neuroimaging changes are found and typical for PCD clinical picture is present. Changes in cognition accompanying neoplastic diseases are significant clinical problem not only in differential diagnosis of dementia, but also it they should be taken into account in interdisciplinary care of above-mentioned group of patients. 

Keywords: cognitive impairment, neoplastic diseases, paraneoplastic neurological syndromes, limbic encephalitis, paraneoplastic cerebellar degeneration
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Rituximab therapy in generalized refractory myasthenia gravis. Case report
Aktualn Neurol 2009, 9 (1), p. 63-66
ABSTRACT

Background: Rituximab is a human-mouse chimeric IgG1 monoclonal antibody directed against antigen CD-20, transmembrane phosphoprotein on B cells. This drug induce depletion of B cells and subsequent reduction in antibody production. Recently there were cases of severe AChR-antibody positive and MuSK-positive myasthenia gravis (MG) successfully treated with rituximab. Case report: Forty-three-year-old women with refractory MG with predominantly generalised weakness in extremities, bulbar symptoms and dyspnea, who presented for the first time in 1992. Thymectomy was perform in 1997. During 15 years of therapy patient had one crise in 1997 and one in 1999. In 2007, she had five hospital admission. She did not respond adequately to acetylcholinesterase inhibitors, thymectomy, repeat plasma exchange and conventional immunosuppressive therapy such as azathioprine, cyclophosphamide and prednisone. For this reason rituximab (MabThera®, Roche) therapy was added. Rituximab was administered at a dose of 375 mg/m2 intravenously according to a protocol every 7 days for 4 weeks. She received also prednisone at a dose of 20 mg and pyridostigmine 180 mg per day all the time. Within 4 weeks therapy she showed maintained clinical improvement. Dyspnea and bulbar symptoms were disappearanced and walking distances was longer. We did not observe serious adverse events, only after first infusion transient oedema of mucosa nasal and oral cavity with concurrent pruritus and after second infusion transient myalgia, chills and subfebrile body temperature were found. Conclusions: In this case use of rituximab leading to significant clinical improvement in refractory myasthenia gravis. The therapy was well tolerated and any serious adverse events were registered. 

Keywords: myasthenia gravis, rituximab, immunosuppression, immunotherapy, antigen CD-20
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