Experience with 64 cases of transpedicular screw-rod fixation of the lumber spine

In this study, a total of 64 patients underwent transpedicular spinal instrumentation using the Texas Scottish Rite Hospital [TSRH] screw- rod system. Surgery was performed for lumbar vertebral column instability secondary to fractures [42 cases], spondylolisthesis [16], vertebral osteomyelitis [2] or postoperative cases [4]. The 34 men and 30 women [mean age 41 years, range 18-61 years] presented with severe back pain. Signs or symptoms of neural compression were noted in 60 patients. Surgery consisted of neural decompression, internal fixation and autogenous bone grafting. Spondylolistheses were fused in situ, without reduction; otherwise, major spinal deformities were corrected. The extent of fusion ranged from one to four motion segments. A 96.9% firm fusion was obtained within a follow-up period ranging from 8 to 30 months. There were no operative deaths. Major complications included one isolated nerve root deficit, two transient nerve root irritation and three wound infections [two deep, and one superficial]. Instrument failure eventually developed in two patients, both of them were asymptomatic with a solid fusion and did not require further treatment. The study revealed that pedicle screw- rod fixation offers biomechanical advantages compared to other forms of internal fixation for the lumbar spine. It enables short-segment fixation with preservation of lumbar lordosis and adjacent normal motion segments. This technique provided a highly successful method to obtain arthrodesis

Operative management of pediatric intracranial arachnoid cysts

In this study, 14 cases of pediatric patients with arachnoid cysts treated between 1995 and 1999 are reported. Six children with mild symptoms and small cysts that remained stable on follow-up studies have not required surgical intervention. Fenestration was done through open craniotomy for two patients and through endoscopy for another two patients. Three of these children treated initially by fenestration showed clinical and radiographic recurrence of the cysts within a period of 2 to 15 months postoperatively and have undergone cystperitoneal shunting. Thus, only one of the four patients initially treated by fenestration remained shunt-independent after a follow-up period of three years. The other four patients were initially treated by cystperitoneal shunting and all improved postoperatively. Shunt revision has been necessary because of cyst recurrence in one of these four patients. Cyst location influenced the success of shunt treatment as none of the five middle cranial fossa cysts treated by shunting required revision

Prognostic factors in traumatic acute subdural hematoma

In this study, data were reviewed for 640 severely head-injured patients [Glasgow Coma Scale [GCS] scores three to seven]. Fifty of these patients had acute subdural hematoma. Standard treatment protocol included aggressive resuscitation measures, control of intracranial pressure [ICP] and operative evacuation of the sizable hematoma. The overall mortality rate was 32% and 48% had functional recovery. The following factors correlated with outcome: Road traffic accident as a mechanism of injury, age over 65 years, admission GCS score of three or four and severe pre- and postoperative brain edema [high ICP]. Although the time interval from injury to operative evacuation of the acute subdural hematoma is crucial in regard to outcome morbidity and mortality, it was not absolutely significant despite the trends indicating that earlier surgery improved outcome

Single brain metastasis

In this study, 24 patients were selected for treatment by partial or complete resection of single cerebral metastasis along the period from 1989 to 2000. None of the studied cases had any systemic disease other than the cancer. Patients were classified into two groups on the basis of whether a gross complete resection or partial resection was performed. Group 1 had gross complete resection, while group 2 had partial resection. Both groups were further subdivided into subgroup A [adjuvant whole-brain radiation therapy] and subgroup B [no adjuvant radiation]. Data were collected for comparing the prognosis and survival among the different groups. Survival data for the eight patients in group 1A [two-year survival 37.5%, five-year survival 25%] were markedly better than those for the six patients in group 1B [two- year survival 16%, five-year survival 0%]. The four patients in group 2A also had superior survival data [two-year survival 25%, three-year survival 25%] when compared with the six patients in group 2B [one- year survival 0%]. Adjuvant whole-brain radiotherapy was significantly associated with improved survival times

Surgery of leptomyelolipoma

In this study, ten patients treated surgically. 50% were 12 years of age or less and 50% were older than 18 years of age. The surgical approach was designed to accomplish untethering of the conus medullaris, debulking of the lipomatous mass compressing the cord, reconstruction of the dural canal and reapproximation of the paraspinal muscles and lumbosacral fascia to prevent future damage. Postoperatively, no patient experienced deterioration of neurological function. Of the symptomatic patients, 67% displayed dramatic improvement or became asymptomatic and 33% experienced stabilization of their deficits. The symptoms most resistant to surgical correction were orthopedic foot deformities and bowel dysfunction, whereas bladder dysfunction, motor weakness and radiculopathies were most responsive to surgical therapy. The study indicated that early surgical repair is important in these cases to avoid irreversible neurological damage

Cervico-dorsal junction spinal injuries [posterior interspinous compression wiring and fusion]

A technique of posterior cervicodorsal interspinous compression wiring and fusion, which offers a significant immediate stability, was presented. Its efficacy in 16 consecutive cases of post-traumatic unstability at the cervicodorsal junction illustrated its utility. The technique involves the passage of an interspinous cerclage wire. Rather than the placement of onlay laminar and facet grafts, a split- thickness tricortical iliac-crest graft was compressed against the involved medial laminae and spinous processes bilaterally. The technique appears to immediately provide a very stable construct, in addition it proved to be a simple and straightforward procedure for the treatment of the unstable cervicodorsal fracture, which may be difficult sometimes to be approached interiorly

Surgical decompression for degenerative lumbar canal stenosis

Fifty patients who underwent decompressive surgery for lumbar canal stenosis between 1989 and 1998 were evaluated to study their long- term outcome. They were followed up for, at least, 3 years. Other patients who did not show up for assessment along the 3-year period were excluded. The range of age at time of presentation for patients was between 42 and 64 years, 60% were over 50 years. There were no coexisting medical diseases in 70% of the cases and the principal disability was lumbar canal stenosis with neurological involvement. The results were categorized as either a surgical success or a failure depending upon the achievement of the study aims within the context of lifestyle and needs. There were no perioperative neurologic complications. Initially, there was a high incidence of success, but recurrence of neurological involvement and persistence of low- back pain occurred in 30% of the studied cases

Chiari I-related syringomyelia [surgical management]

In this study, ten patients with Chiari I malformation and associated syringomyelia were subjected to surgical suboccipital decompression of the craniocervical junction. Complete neurological recovery with collapse of the syrinx was demonstrated in four patients. Two patients showed good but incomplete recovery along the three- year follow up period in spite of complete collapse of the cavity. Three patients showed stabilization of their neurological condition with no appreciable reversal of the preoperative neurological impairment, but with a reduction of the intramedullary cyst volume. One patient died early postoperatively. A ventriculo-peritoneal shunting of cerebrospinal fluid was done before considering suboccipital decompression for one patient due to the evident hydrocephalus. Postoperatively, one patient developed unilateral bulbar palsy and two patients showed cerebrospinal fluid leak that responded to repeated lumbar puncture satisfactorily. One patient died on the sixth postoperative day due to pulmonary embolism. The progressive destructive nature to the neural tissues by the tense enlarging cyst of syringomyelia makes the surgical intervention inevitable in most of the cases. As a principle, treatment should be directed against the cause of accumulation and intramedullary propagation of the fluid by normalizing the cerebrospinal fluid pathway

Post-traumatic cerebrospinal fluid rhinorrhea [minimally invasive procedures reduce number of craniotomies]

In this study, 212 patients with post-traumatic cerebrospinal fluid [CSF] rhinorrhea were evaluated shortly [within few hours] after head trauma, they were arranged into two groups [A and B]. It was concluded that in post-traumatic CSF rhinorrhea whenever possible, the repair of the dura [during early surgical intervention for another emergency intracranial lesions] gives an excellent chance for clean healing of the dura-arachnoid tear with subsequently less incidence of complications and CSF leak. Otherwise, conservative management including minimally invasive procedures can achieve spontaneous sealing of the fistulae in a high percentage of patients. Trans- sphenoidal approach is another less invasive procedure that reduces the overall number of craniotomies for the treatment of persistent CSF rhinorrhea

Neurobrucellosis [a complication of systemic brucellosis]

This detailed study was performed on six patients presented with diverse neurological features of meningoencephalitis, myelopathy or radiculopathy syndromes. The uncommon possibility of brucellosis as an etiological factor was not born in mind early for most of the patients delaying the proper management to the stage of chronicity and complications. Rapid improvement was recorded after proper diagnosis and adequate antibiotic therapy but long st and ing cases responded to a lesser degree and one patient died. The purpose of this article was to emphasize the importance of brucellosis as a differential diagnostic probability for several neurological syndromes

Revision of anterior cervical diskectomy and arthrodesis

In this study, eight patients were managed operatively after the failure of an anterior cervical discectomy and arthrodesis. Seven patients had a failure of a previous arthrodesis without deformity [but with different combinations of neck pains, radiculopathy and myelopathy], two of them showed dislodgment of the graft after a Cloward arthrodesis. The last patient showed a failure due to a kyphotic deformity with residual spinal canal compromise after discectomy and a Cloward arthrodesis. Operative revision of the pseudoarthrosis consisted of a repeated resection of the disc space in the area of the failed arthrodesis, followed by repeated anterior Robinson arthrodesis with decompression of the nerve root or the spinal cord. Anterior corpectomy [vertebral body resection] and strut grafting were done for one patient with cervical kyphosis. Revisions were performed from six months to five years after the initial operation. The follow up period after revision ranged from 9-42 months. All reoperated patients got solid fusion of the graft and relief of neck pain with varying degree of neurological recovery

Intraspinal epidermoid cysts

In this study, five patients with the rare epidermoid cyst of the intraspinal lumbosacral region were evaluated clinically and radiologically. All patients were presented by progressive neurological impairment of varying severity that m and ated surgical management for the removal of the cystic mass. Postoperative excellent improvement was obtained for four patients showing a restoration of normal muscle power with a return to normal daily activities. One patient got a residual neurologic deficit that did not improve during the follow up period, while another patient developed an asymptomatic leptomeningeal cyst that required no further management. Minor transient forms of meningismus occurred in two patients, in spite of the adequate hydrocortisone medication perioperatively. The pathology, etiology, epidemiology, clinical features, imaging characteristics and surgical treatment of such rare tumors were discussed. Magnetic resonance imaging [MRI] reduced the delay in the diagnosis of intraspinal tumors but it should be guided by the clinical judgment