Epidurography

Since its introduction into clinical practice in 1921, millions of epidurals are performed daily around the world. Anesthesiologists were quick to grasp its use for prolonged or continuous analgesia and routinely use it alone or in combination with general anesthesia. It has been found to be associated with less complications as compared to spinal analgesia and has taken a major chunk out of spinal practice. The success of epidural depends upon successful location and deposition of drugs into the epidural space. Blind identification of epidural space by loss of resistance or negative epidural space pressure has resulted in mixed results. The figures vary among the researchers but in about 25-30% cases, drugs are deposited at wrong place [outside epidural space]. Epidurography offers the best method of confirming the needle or catheter tip location in the space, and has evolved itself a standard practice now. Although very rarely adverse reactions to the technique or the contrast media have been reported, the method is highly recommendable and the pain practitioners and anesthesiologists are encouraged to use it more judiciously

C-T Metrizamid and surgical corelation in Spina Bifida Cystica

This work was conducted on 38 cases of spina bifida cystica with employment of C.T. mitrizamid as preliminary methods of investigation and treated by microsurgical technique. The work showed that the agreement of surgical verification with C.T. mitrizamid was in 32 cases with percentage of 84.21%. The disagreement was only in 15.79% of the cases [6 cases]. So, C.T. mitrizamid is trustful method of investigation as regard to study of both vertebral lipoma in wide anomalies. MRI can be use as confirmatory method if intraspinal lipoma in wide spinal canal suspected to give more delineation of the soft tissue contents

Diagnosis of Congenital Otogenic CSF Fistula Combined with Recurrent Meningitis in Children / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Otogenic cerebrospinal fluid (CSF)fistula referrs to the abnormal communication between the CSF and the middle ear space due to defects in the inner ear, and is one of the causes of recurrent meningitis. MATERIALS AND METHODS: We report on five children with congenital otogenic CSF fistula, presented by recurrent meningitis and confirmed by surgical exploration. We also propose diagnostic steps for detecting otogenic fistula in the children based on our experiences and paper review. RESULTS: We used the metrizamide CT in the diagnostic procedure for most cases, although not all. The temporal bone CT was an useful initial diagnostic step for clinically suspicious cases. CONCLUSION: No one test or combination of specific tests were found to accurately predict the presence or absence of CSF fistula. It is thought that the only way to diagnose the CSF fistula is by surgical exploration. If the CSF fistula was suspected, aggressive diagnostic evaluation was needed in order to prevent recurrence.

A case of chemical meningitis after myelography

Meningeal irritation signs sometimes develop after myelography due to bacterial infection by contamination during the procedure or chemical irritiation by contrast media itself. CSF profiles of chemical meningitis often mimick those of bacterial meningitis, sometimes causing difficulty in differentiation, but in that case clinical course soon reverse in short time without any complication. Postmyelography chemical meningitis by metrizamide (AmipaqueR) has been well described but iohexol (OmnipaqueR) has rarely been reported to cause chemical meningitis. We experienced a patient of chemical meningitis by iohexol and here descibe the case.

A Case of Normal Volume Hydrocephalus

The normal volume hydrocephalus is a serious, late complication of cerebrospinal fluid shunting procedures. It is characterized by persistent symptoms of headaches, vomiting and/or lethargy in shunted patients and is associated with normal-sized or slightly decreased ventricles. The subependymal gliosis that has been described in experimental and human hydrocephalus was offered as an explanation for the increased elastance in this condition. This 21-yearold male was shunted at 13 years of age for hydrocephalus secondary to pineal gland tumor. He remained asymptomatic for approximately 7 years before admission, when headaches and vomiting developed. A brain CT showed nearly normal-sized ventricles and spinal tapping documented elevated intracranial pressure (300mg CSF). A metrizamide shuntgram suggested obstruction of distal abdominal shunt catheter. After a revision of the distal shunt catheter, the patient became asymptomatic. On follow-up brain CT, no significant decrease in ventricle size was noted.

Thoracic Spinal Canal Stenosis Associated with Thickened and Calcified Ligamentum

The authors report four cases of thoracic spinal canal stenosis caused by thickening of the laminar arch, facet joint and ligamentum flavum. Main symptoms of this disease are gait disturbance and spastic motor seakness, numbness of both legs and feet. Metrizamide myelogram, CT and MRI are most useful diagnostic tools. Sufficient postetior decompressive laminectomy and medial facetectomy are treatment of choice and resulting in satisfactory improvement in 3 patients with fair course in 1 case.

Spontaneous Lumbar Epidural Hematoma: Case Report

The authers report a case of spontaneous lumbar epidural hematoma in a 16-year-old boy who developed lumbago, paraparesis and gait disturbance over a six-day period. Metrizamide myelography and CT demonstrated the extradural mass lesion at the L3-4 level. MRI revealed a hyperintense mass on T1-weighted and T2-weighted sequences and it enabled to make diagnosis of epidural hematoma. The patient had full postsurgical recovery. We concludes MRI is the most helpful diagnosis modality for spinal epidural hematoma.

Two Cases of Thoracic Myelopathy Secondary to Ossification of the Ligamentum Flavum

Hypertrophied ligamentum flavum is not a common cause of myelopathy. Only a minority of cases in the previous reports of myelopathy or radiculopathy secondary to thickening of the ligamentum f lavum had calcification of the ligamentum. We report two cases of thoracic myelopathy caused by ossified ligamentum flavum. One case was a twenty-five year old female who complained of weakness of lower limbs. The other was a fifty-three year old male who complained of tingling sensation on both lower extremities and weakness of right leg. These two patients showed weakness of lower extremities associated with hypesthesia below the level of calcified ligamentum flavum, positive ankle clonus, extensor plantar response, and hyperreflexia. Magnetic resonance imaging (MRI) showed clearly the spinal cord compression at the second to fourth thoracic level by a low-intensity-signal lesion. Metrizamide myelography with computerized tomography showed precise preoperative diagnosis and anatomic localization of the lesion. About one month after laminectomy and removal of the ossified ligaments flava, there was improvement of weakness, hypesthesia and ankle clonus.

The Supine and Prone Position for Computed Tomographic Myelography(CTM) of the Lumbar Spine: Change of Gantry Angle

For evaluating the lumbar disc space, the fact that the postmyelography computed tomography was more accurate than computed tomography or myelography is well-known. But the technical difficulty is limitation of gantry angle. The prone position scanning may help to lessen this trouble. A prospective computed tomographic scanning was performed in both the prone and supine position on 43 patients, who had low back pain. The angle between the vertebral end plate and vertical line was measured in both position at L3-4, L4-5 and L5-S1 interspaces. The advantages of prone scanning in spinal aligment was noted at L5-S1 disc space(79.1%) and also more desirable if computed tomography was performed with metrizamide. With above advantages, the evaluation of bulging annulus was became more easier.

Three Cases of Thoracic Myelopathy due to Ligamentum Flavum Ossification

Ossification of ligamentum flavum is a very rare disease and one of the new disease entities in myelopathy. We report three cases of ossification of ligamentum flavum in thoracic spine causing thoracic myelopathy. Main symptoms of this disease are numbness of both legs and feet, gait disturbance and spastic motor weakness. Simple spine X-ray, metrizamide myelogram, CT and MRI are most useful diagnostic tools. Sufficient decompressive laminectomy and facetectomy are treatment of choice.

Three Cases of Ossification of Ligamentum Flavum Causing Thoracic Myelopathy

The authors report three cases of ossification of ligamentum flavum causing thoracic myelopathy. The symptoms of all cases were numbness in the legs and feet and motor weakness. Preoperative diagnosis were simple spine X-ray, metrizamide CT and magnetic resonance imaging. There was satisfactory improvement in all cases after total laminectomy and medial facetectomy.

Correlaçäo entre tomografia computadorizada e diagnóstico cirúrgico dos tumores intrarraquianos / Correlation between computed tomography and surgical diagnosis of intraspinal tumors

Relatamos a contribuiçäo da tomografia computadorizada (TC) no diagnóstico e tratamento cirúrgico de 10 tumores intrarraquianos. A TC sem contraste, realizada em 2 pacientes, näo foi suficiente para demonstrar a patología. Salientamos a necessidade da utilizaçäo de contraste para o diagnóstico em todos os casos estudados. Em 9 pacientes o diagnóstico foi confirmado pela TC realizada após injeçäo intratecal de metrizamida (TC-metrizamida). No caso restante, o diagnóstico foi feito mediante administraçäo de contraste iodado (conray) por via endovenosa, que contrastou o tumor em toda sua extensäo

Surgical Repair of Cerebrospinal Fluid Rhinorrhea: Report of Five Operative Cases

This report describes five cases of cerebrospinal fluid(CSF) rhinorrhea which were caused by head injury in four cases and developed after surgical removal of brain tumor in one case. Intrathecally-enhanced brain computerized tomography(CT) with metrizamide, in addition to isotope cisternography, was helpful in localization of the CSF leakage site. All five cases which could not be managed conservatively were successfully repaired by surgical means using biological fibrin glue.

Isolated Fourth Ventricle Hydrocephalus

Mental deterioration and signs of cerebellar dysfunction developed 5 years after lateral ventricle shunting in 36-year-old hydrocephalic female patient. Fourth ventricle enlargement was seen on CT scan. Reevaluation of the cerebrospinal fluid pathways with metrizamide ventriculography showed isolated fourth ventricle with aqueductal stenosis. Shunting of the fourth ventricle with an Y-connector returned the patient to normal neurological status.

Thoracic Spinal Stenosis

A stenotic spinal canal in the cervical or lumbar region is a well-known clinical entity. However, stenosis involving a thoracic vertebra is rarely mentioned in the literature. Improved neuroimaging facilities, especially MRI, let us detect the thoracic canal stenosis not so infrequently as in the past years. The authors are reporting six operative cases of thoracic myelopathy associated with thoracic spinal stenosis. Motor & sensory abnormalities were found in all cases during the clinical course. Magnetic resonance imaging and Metrizamide CT scanning were useful in the diagnosis of thoracic spinal stenosis. Treatment consited of wide posterior decompression resulting in symptomatic improvement in five of six patients.

A Case of Third Ventricular Cysticercosis

Cerebral cysticercosis is relatively common disease in Korea. But cysts in the ventricular system are rare form. In the ventricular system, they occur most frequently in the 4th ventricle, more rarely in the lateral and 3rd ventricle. We have recently experienced a case of cerebral cysticercosis which involved the 3rd ventricle. A sixty-year old man was admitted because of generalized seizure attack followed by drowsy mentation. On admission, there were no specific localizing and lateralizing neurological abnormalities except bilateral, mild degree optic papilledema. Brain CT scan after intraventricular metrizamide administration disclose a cystic mass in the third ventricle. And the serum ELISA test was positive(patient's titer : 0.31, normal : below 0.18). Anterior transcallosal approach was performed and cystic mass was removed from the third ventricle. Pathological diagnosis of the specimen was cysticercosis. Following surgery, the patient's symptom cleared up and papilledema disappeared gradually.

Clinical Evaluation of Cervical Ossification of the Posterior Longitudinal Ligament

The authors treated 32 patients with Ossification of the Posterior Longitudinal Ligament(OPLL). Seventeen of these patient had surgery during the past 1 year between 1987 and 1988. In this study we present a radiological and clinical analysis of these cases with a literature review. We also discuss a clinical system of grading, different types of radiological patterns, the indication of surgical treatment and the choice of operative methods. 1) The incidence of the cervical OPLL was about 5.4% in our annual study, which was based on the cervical CT and CTM. 2) The highest incidence was in patients 50-60 years of age and male: female ratio was about 3:1. 3) The highest incidence was in C5, C6 and C4 levels of cervical spine and two and three level involvement was prominent. 4) The pattern of OPLL was devided into a continuous type (21%), a multiple segmented type(48%), a mixed type(25%), a localized type(6%). 5) Absolute diameter did not always parallel the extent of spinal cord signs as did the percentage of spinal canal narrowing. 6) In cases of a clinical grading of more than III, surgery must be considered. In grade II, surgery is indicative if conservative management failed to improve the clinical symptoms. 7) For the evaluation of the cervical OPLL, the CT-Scan of CT metrizamide myelography was more useful method. 8) Cervical Corpectomy and fusion with or without bone cement were found to be advisable in Cases of cervical OPLL.

Management of Intracranial Arachnoid Cysts in Children

14 supratentorial and 6 infratentorial arachnoid cysts, diagnosed and treated at Kangnam St Mary's Hospital from 1983 to 1988, are reported. The most common presenting symptoms in children were craniomegaly, delayed development, increased ICP and neurological focal signs. Neuroradiological examination included plain skull X-ray, brain CT and metrizamide CT or isotope study. Therapeutic criteria according to the clinical and radiological findings were reviewed. The results were as follows; 1) The patient below age of 2 yrs who's brain had a potent ability of growth should be operated in any cases for reducing mass effect. 2) In sylvian lesion, Type II and III according to the classification of Galassi were well treated with C-P snunt. 3) In infratentorial lesion, all patients had hydrocephalus and the patient who had communicated with subarachnoid space in metrizamide CT were well treated with V-P shunt and who not communicated with subarachnoid space was well treated with Y-shunt. 4) We had good results by fenestration above the age of 3 yrs and by C-P shunt under the age of 2 yrs in supratentorial lesion.

Surgical Treatment of Spontaneous and Traumatic Delayed Cerebrospinal Fluid(CSF) Rhinorrhea

The authors presented 9 cases of surgically treated CSF rhinorrhea, two of which were spontaneous and 7 were traumatic delayed. The duration of leakage was longer than 1 month in most cases and seven of the nine cases were complicated by meningitis. The leakage site was most accurately detected by metrizamide computed tomographic cisternography(MCTC) and the most frequent leakage site was the cribriform plate. Good surgical results were obtained by direct repair and/or shunt without recurrence during follow-up period from 7 months to 2 years.

A Case of Herpes Zoster Myelitis

Herpes zoster myelitis is quite rare and it's MRI findings have not been reported. We report a patient who developed a progressive myelopathy after a characteristic herpes zoster skin lesions involving right C3 and C4 dermatomes. The lesions were recognizable in T1-weighted images of MRI as hypointense areas in the central portion of the long segment of the spinal cord, which became more prominent in T2-weighted image as increased signal intensities. In this patient computed tomographic metrizamide myelography (CTMM) showed no detectable intra or extramedullary lesion except a slight bulging of the cervical cord.