Idiopathic Hypertrophic Spinal Pachymeningitis with an Osteolytic Lesion

Idiopathic hypertrophic spinal pachymeningitis (IHSP) is a chronic, progressive, inflammatory disorder characterized by marked fibrosis of the spinal dura mater with unknown etiology. According to the location of the lesion, it might induce neurologic deficits by compression of spinal cord and nerve root. A 58-year old female with a 3-year history of progressive weakness in both lower extremities was referred to our institute. Spinal computed tomography (CT) scan showed an osteolytic lesion involving base of the C6 spinous process with adjacent epidural mass. Magnetic resonance imaging (MRI) revealed an epidural mass involving dorsal aspect of cervical spinal canal from C5 to C7 level, with low signal intensity on T1 and T2 weighted images and non-enhancement on T1 weighted-enhanced images. We decided to undertake surgical exploration. At the operation field, there was yellow colored, thickened fibrous tissue over the dura mater. The lesion was removed totally, and decompression of spinal cord was achieved. Symptoms improved partially after the operation. Histopathologically, fibrotic pachymeninges with scanty inflammatory cells was revealed, which was compatible with diagnosis of idiopathic hypertrophic pachymeningitis. Six months after operation, motor power grade of both lower extremities was normal on physical examination. However, the patient still complained of mild weakness in the right lower extremity. Although the nature of IHSP is generally indolent, decompressive surgery should be considered for the patient with definite or progressive neurologic symptoms in order to prevent further deterioration. In addition, IHSP can present as an osteolytic lesion. Differential diagnosis with neoplastic disease, including giant cell tumor, is important.

Where are We Now with Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction?

In spite of the best medical treatment, large hemispheric infarction, resulting from acute occlusion of either the internal carotid or the proximal middle cerebral artery with insufficient collateral blood flow is associated with a high case fatality rate of approximately 60%. Thus, a decompressive hemicraniectomy is considered a life-saving procedure for this devastating disease. Findings of three recent randomized, controlled clinical trials and their meta-analysis showed that early surgical decompression not only reduced the number of case fatalities but also increased the incidence of favorable outcomes. The authors review the pathophysiology, historical background in previous studies, operative timing, surgical technique and clinical outcomes of surgical decompression for malignant hemispheric infarction.

Descompresión orbitaria: técnica combinada de acceso mínimo / Orbital decompression: combined technique of minimum access

La orbitopatía endocrina es una enfermedad inflamatoria de origen autoinmune que se asocia a trastornos metabólicos de la glándula tiroides caracterizada por exoftalmos, asociado a acúmulo de células linfoides y otros en la grasa orbitaria o engrosamiento del vientre de los músculos extraoculares con predominio de rectos superior, recto medio, inferior y retracción palpebral por compromiso del elevador del parpado. En etapas iníciales se presenta dolor crónico de carácter inflamatorio recidivante, disfunción de la película lagrimal y exposición y en etapas finales fibrosis de estructuras orbitales, leucomas y perforaciones oculares. Complementario al manejo endocrinológico y al manejo antiinflamatorio y del ojo seco, se han adoptado medidas quirúrgicas para el manejo del síndrome de dolor crónico, exposición y cosmesis. Queremos así dar a conocer nuestros avances preliminares en el tratamiento quirúrgico de esta enfermedad, mostrando los resultados con la utilización de una técnica combinada de descompresión endoscópica etmoidal trasnasal para la pared medial de la órbita, junto con un abordaje transconjuntival para el manejo del piso orbitario en toda su extensión. Método: Proponemos una técnica combinada conjunta multidisciplinaria de otorrinolaringología y oftalmología y mostrando los primeros resultados en una experiencia de 6 años. Conclusiones: Nuestros resultados son comparables a los reportados en la literatura mundial con técnicas convencionales o endoscópicas (1, 2, 3). Resaltamos la ventaja de la excelente exposición anatómica a nivel del piso orbitario y el manejo del nervio infraorbitario sin distopia y la ausencia de complicaciones por sangrado etmoidal o fistulas de LCR.

Endocrine orbitopathy is an inflammatory autoimmune disease, associated to metabolic disorders of the thyroid gland. Its main characteristic is the presence of exophthalmoses associated to the accumulation of lymphocytes and others in the orbital fat or by the thickening of the womb of the extra ocular muscles with predominance of superior rectus, medial rectus, and inferior rectus and eyelid retraction due to the compromise of the levator palpebrae superioris muscle. There is some chronic pain featuring some relapsing swelling, there can be malfunctioning and exposition of the lachrymal screen during the early stages of the disease, and during the final stages of the disease there can be some fibrosis in the orbit structures, leukoma as well as ocular perforations. As a complement to the treatment from the endocrine standpoint, and to the anti inflammatory and dry eye treatments, some surgical measures have been adopted in order to treat the exposition, cosmesis and chronic pain syndrome. We would like to disclose our preliminary advancements to surgically treat this disease, by showing the results obtained from using a combined transnasal ethmoidal endoscopic decompression technique for the medial rectus of the orbit together with the trans conjunctival approach to treat the entire orbital floor. Method: We are proposing an Otorhinolaryngology and Ophthalmology combined multi- disciplined technique and exhibiting the first set of results in a 6 year experience. Conclusions: Our results can be compared to the ones that have been reported on both conventional and endoscopic techniques in the literature available around the world. (1, 2, 3) We want to highlight the excellent anatomical exhibition at orbital floor level as well as the handling of the infra orbital nerve with no dystopia and the lack of complications due to ethmoidal bleeding or fistulas to the LCR.

Efficacy of Microdecompression with Microscope and Tubular Retractor in Lumbar Foraminal Stenosis: Surgical Technique and Clinical Outcomes

OBJECTIVE: The objective of this study is to evaluate the efficacy of microdecompression (MD) with microscope and tubular retractor in lumbar foraminal stenosis (FS) and to analyze the clinical outcomes. METHODS: From January 2006 to December 2007, 22 patients with symptomatic lumbar FS underwent conventional decompressive surgery (CDS) and MD was performed in other 20 patients. Clinical outcome was measured using a Visual Analogue Scale (VAS) and Macnab?fs criteria. Spinal instability was determined by radiologic assessment of flexion-extension radiographs. RESULTS: The CDS group included 14 men and 8 women. The MD group included 14 men and 6 women. The mean age was 66.2 years (range, 46-80 yrs) in the CDS group and 65.4 years (range, 59-74 yrs) in the MD group. Average follow-up periods were 18.6 months in the CDS group and 16.5 months in the MD group. Mean operating time was 126 minutes in the CDS group and 168 minutes in the MD group. The mean VAS of back pain decreased from 2.68 to 1.36 in the CDS group and from 2.85 to 1.25 in the MD group. The mean VAS score of leg pain decrea- sed from 6.68 to 1.48 in the CDS group and from 6.65 to 1.40 in the MD group. The success rate of CDS group was 86.3 % (19/22), compared with 85.0% (17/20) for MD group. Radiologically, there was no spinal instability. CONCLUSION:MD could achieve neural decompression and offer an effective treatment of lumbar FS. However it was a technically demanding procedure and effective in limited operative indications. We need to consider long-term follow-up.

Surgical Management of Acute Stroke

Stroke is a most common neurological disease leading to mortality and morbidity. Many clinical evidences confirm that medical treatment including thrombolytic and antithrombotic therapy may improve the clinical outcome in patients with acute ischemic stroke. However, little information exists about effectiveness and safety of reperfusion surgery such as emergency carotid endarterectomy and extracranial-intracranial bypass surgery in patients with acute ischemic stroke and limits its wide application. Recent pooled analysis of three randomized controlled clinical trials-DECIMAL (decompressive craniectomy in malignant middle cerebral artery infarcts) trial; DESTINY (decompressive surgery for the treatment of malignant infarction of the middle cerebral artery) trial; and HAMLET (hemicraniectomy after middle cerebral artery infarction with life-threatening edema trial) reported decompressive surgery undertaken within 48 hours of stroke onset in patients with malignant middle cerebral artery infarction reduced mortality and morbidity. However, decompressive surgery in patients with malignant middle cerebral artery infarction should be done according to the clinical conditions of individual patients. No clear evidences are present on that craniotomy, minimally invasive surgery, and early clot evacuation are effective on functional outcome of patients with spontaneous intracerebral hemorrhage compared with initial conservative therapy. In conclusion, a lot of well-designed studies are needed to recommend appropriate surgical management in patients with acute ischemic and hemorrhagic stroke.

Use of decompressive craniectomy in the treatment of hemispheric infarction / Uso da craniectomia descompressiva no tratamento do acidente vascular cerebral isquêmico hemisférico

Decompressive craniectomy (DC) has demonstrated efficacy in reducing mortality in hemispheric infarction of the middle cerebral artery. The aim of our study was to compare the outcome of patients submitted to DC to patients treated in a conservative way. Eighteen patients were submitted to DC and 14 received conservative treatment. Neurological status was assessed by the Glasgow Coma Score and National Institutes of Health Stroke Scale score. Mortality, modified Rankin Scale and Barthel Index scores were assessed at 90 days to evaluate outcome. We did not observe reduction in overall mortality and functional outcome in patients submitted to DC. The differences between our group and previously published series are probably related to the neurological status of the patients at the time of therapeutic decision.

Craniectomia descompressiva (CD) tem demonstrado eficácia em reduzir a mortalidade em pacientes com infarto hemisférico (IH) da artéria cerebral média. Este estudo avaliou o prognóstico dos pacientes submetidos a CD comparando a pacientes com IH tratados de maneira conservadora. Dezoito pacientes foram submetidos a CD e 14 receberam tratamento conservador. Escala de Coma de Glasgow e Escala de AVC do National Institutes of Health foram utilizadas para graduar o déficit neurológico. A mortalidade, bem como os escores obtidos na escala modificada de Rankin e índice de Barthel foram avaliados em 90 dias. Não foi observada redução de mortalidade nos pacientes submetidos a CD. Essa diferença entre os nossos resultados e os estudos publicados previamente se deve, provavelmente, à decisão cirúrgica tardia em pacientes com sinais clínicos de herniação cerebral.

Multiple, Sequential, Remote Intracranial Hematomas Following Cranioplasty

The intracranial hemorrhage in regions remote from the site of initial operations is unusual but may present as fatal surgical complication. We report a rare case of multiple, sequential, remote intracranial hematomas after cranioplasty in a patient who did not have any prior risk factors. A 51-years-old man was transferred to the hospital after a head trauma. The brain computed tomography (CT) revealed acute subdural hemorrhage on the right hemisphere with prominent midline shifting. After performing decompressive craniectomy and hematoma removal, the patient recovered without any complications. However, the patient showed neurological deterioration immediately after cranioplasty, which was done three months after the first surgery. There was extensive hemorrhage in the posterior fossa remote from the site of the initial operation site. The brain CT taken soon after removing this hematoma evacuation displayed large epidural hematoma on the left hemisphere. This case represents posterior fossa hemorrhage after supratentorial procedure and sequential delayed hematoma on the contralateral supratentorial region thus seems very rare surgical complications. Despite several possible pathogenetic mechanisms for such remote hematomas, there are usually no clear cut relationships with each case as in our patient. However, for the successful outcome, prompt evaluation and intensive management seem mandatory.

Decompressive Surgery for Massive Hemispheric Infarction / 中国康复理论与实践

@#Objective To sum up the experience of decompressive surgery for the acute massive hemispheric infarction to determine its beneficial effects.MethodsRetrospectively study 6 patients receiving early decompressive craniotomy because of deterioration after infarction.Results 5 patients survived,4 of them recovered to the good level of daily activity (Barthel index ≥60) one year after rehabilitation.One senile patient died of pulmonary infection.ConclusionThe decompressive surgery is an effective method on the survival and functionary recovery for the patients with deteriorating massive cerebral infarction.

Surgical Experiences of the Tarsal Tunnel Syndrome

OBJECTIVE: Tarsal tunnel syndrome is a rare compressive neuropathy. In Korea, the reported cases of the tarsal tunnel syndrome are mainly related to diagnosis, so there are only a few reports about the surgical result. We report the significance of the decompressive surgery for the tarsal tunnel syndrome. METHODS: Seven patients with tarsal tunnel syndrome were treated surgically. The patients were aged 31-70 years (mean 53.1 years), and all of them complained of pain or dysesthesia of the sole of the foot. The posterior tibial nerve and its branches were decompressed through the flexor retinaculum and under the abductor hallucis muscle fascia. RESULTS: Surgical decompression was beneficial in most patients with tarsal tunnel syndrome in their feet. Neither wound infection nor recurrence of symptoms was found during the follow up period (mean 12.9 months). CONCLUSION: Surgical decompression is the good option for the treatment of the tarsal tunnel syndrome, especially in the cases of short symptom duration or mass lesion.

Early Decompressive Surgery for Compressive Neuropathy by Hematoma after Posterior Spinal Decompressive Surgery / 대한척추외과학회지

STUDY DESIGN: A retrospective analysis was performed to identify the diagnostic and therapeutic factors related to postoperative compressive neuropathy by hematoma after posterior spinal decompressive surgery. OBJECTIVES: To document by analysis the clinical course of postoperative compressive neuropathy by hematoma, the efficacy of early surgical decompression, and to recommend methods of prevention. SUMMARY OF LITERATURE REVIEW: Various diagnostic and treatment modalities have been applied to postoperative compressive neuropathy after spinal surgery. However, the timing of surgical decompression remains controversial. MATERIALS AND METHODS: Five cases of postoperative compressive neuropathy after posterior spinal decompressive surgery, which occurred from May 1996 to May 2000, were investigated in terms of causes, clinical courses, and management profiles after early surgical decompression, and final outcome. RESULTS: Five cases (2.14%) among 234 patients were managed by re-decompression including the evacuation of hematoma. Four cases, which had been managed by earlier surgical decompression showed neurologic improvement after 2 postoperative weeks, and achieved favorable clinical results without grave neurologic sequelae. However, in one case, in which surgical decompression had been delayed, weakness of the peroneii remained. CONCLUSION: Early evacuation of hematoma achieved a more favorable result than a delayed operation. Early diagnosis and prompt surgical decompression is recommended to reduce neurologic sequelae.

Effect of Decompressive Surgery on Neurological Outcome Following Incomplete Cord Injury of the Mid and Lower Cervical Spines

To determine the effects of decompressive surgery on neurological outcome following incomplete cord injury of the mid and lower cervical spines, 44 patients(decompression and stabilization group: stabilization or conservative treatment group=21:23) who underwent operations between 1993 and 1995 were retrospectively reviewed. We compared neurological outcome by Frankel's grade, Prolo economic and functional rating scale, and final ambulatory status between two groups. Also, we analysed MRI findings related to neurologic outcome in these cervical cord injured patients. With regard to upgrading scale by Frankel's grade, decompressive surgery group was more improved(98% vs 78%). With regard to Prolo's scale, decompressive surgery group were excellent in 24%, good in 52%, and fair in 24%. Stabilization only or conservative treatment group were as follows: excellent(22%), good(39%), fair(30%), and poor (9%). In the viewpoint of walking status, the result of decompressive surgery group was better(90% vs 74%). Initial MRI findings and neurological assesment correlated with neurological recovery. In conclusion, decompressive surgery may be more effective in patients with incomplete cord injury on mid or lower cervical spines when there are cord compressive lesions such as traumatic disc herniation, spondylotic spur, bony impingement in the spinal canal, and irreducible spinal malalignment unless major intramedullary hemorrhage is present.

Clinical Analysis of Bone Fusion for Spinal Stenosis with and without Instrumentation

Spinal stenosis has several types of etiology such as degenerative, spondylolisthetic and postoperative, etc. Operative management for spinal stenosis is adequate decompression and stabilization of the unstable lumbar spine created by the decompressive procedure. We analysed 52 operative cases of spinal stenosis delete from January 1994 to October 1996. The following results were obtained 1) The male and female ratio was 1:1.9 and mean age was 52.1 years old 2) Mean follow-up period was 20.3 months 3) The involved site was one level in(28)(53.9%), two level in(19)(36.5%), and three levels in(5)(9.6%) 4) For decompression method, total laminectomy combined with foraminotomy and facetectomy was employed procedure. 5) For stabilization, bilateral posterolateral fusion was performed in major damaged facet joint and transverse process. Instrumentation was combined in 61.5% delete of all cases 6) According to the criteria of Kirkaldy-willis, excellent and good results were shown in 90.6% of fused group with instrumentation and 85% of fused group without instrumentation.

Surgical Decompression for Acute Brain Infarction

We present 15 patients with progressive neurological deterioration while on medical treatment for massive cerebral or cerebellar edema due to large cerebral or cerebellar infarction. Clinical signs of uncal herniation were present in 10 of these patients. Remaining five patients showed progressive neurological deterioration accompanied with impending herniation. Brain CT confirmed mass effect from cerebral or cerebellar edema in all cases. All 15 patients were treated with decompressive craniectomy, duroplasty and/or ventriculostomy. Nine patients showed good results and six patients had poor results. As compared with poor result group, good result group had high score of Glass Gow Coma Scale(GCS) on admission(12.8 vs. 8.3 on average) and time from worsening to operation is shorter(8.8 vs. 21.3hrs on average). Infarction was all on right side and hearniation sign just before operation appeared infrequently in good result group. These results suggest that decompressive surgery can be effective life saving procedure for massive cerebral edema after large brain infarction, especially in cases with right side lesion, high GCS score on admission, and pertinent timing of operation(before occurrance of irreversible brain stem damage due to herniation).

Dorsal Third Ventricular Cyst

The following is a report of a case of dorsal third ventricular cyst in a 13-year-old boy. The radiological appearance of such cystic malformation is similar to that of 'holoprosencephaly'. However, the dorsal third ventricular cyst has a developmental and clinical course more similar to those of arachnoid cysts than the holoprosencephalies. These lesions seem to be responsive to treatment of early decompressive surgery.

Two Cases of Cerebellar Infarction

Occlusion of vertebro-basilar artery and its branches can produce massive cerebellar lesion with edematous swelling from ischemia and accompanying hemorrhage. Recognition of this massive cerebellar lesion is essential, because it compresses the brain stem and rapidly leads to coma and death unless immediate surgical decompression of posterior fossa is performed. However, surgery might not be beneficial if the arterial occlusion had simultaneously produced and extensive infarction in the brain stem. The clinical and radiological findings are important in determining the optimum therapy and indication for decompressive surgery. CT scan was the most useful diagnostic test. Prompt and correct diagnosis of this illness is required to ensure adequate therapy. We are presenting two cases of cerebellar infarction, which have quite different clinical pictures and courses. One case has progressive headache for 2 months, which was misdiagnosed as tumorous condition and suboccipital craniectomy was performed but died due to brain swelling. The other one has acute course with compression of brain stem 24hr after onset of sudden headache and suboccipital decompressive surgery was performed and the patient recovered successfully.