Missile injuries of the spine.

Between 1995 and 2000, 22 cases with low velocity missile injuries of the spine and spinal cord were treated in three service hospitals. All were adult males, with a mean age of 30.7 years. The wounds were caused by splinters in 18 (82%) and bullets in 4 (18%). Twelve patients received more than one splinter. The cervical and thoracic spines were most frequently involved. In 7 cases, there were injuries to other organs. There was extensive initial deficit (quadriplegia, paraplegia) in 18 (82%) cases, while 4 (18%) had partial deficits. The patients were evaluated by spine radiographs. Myelography was done in 4, CT myelography in 11 and MRI in 4 patients. Two patients had intramedullary hematoma without any skeletal injury, and were treated conservatively. Seventeen patients were treated operatively, and associated injuries of other organs received priority management. Surgery was in the form of debridement, exploration of the spinal cord, hemostasis, decompression and dural repair. Steroids and antibiotics were given routinely. Three patients (2 with cervical and 1 with thoracic spine injury) died preoperatively, and 1 (with dorsolumbar injury) died in the postoperative period due to multi-organ injury. Patients with complete injury remained completely paralyzed, while those with an incomplete injury showed improvement in their neurological grades. The initial neurological grade is the best prognostic indicator, and these injuries are often accompanied by multi-organ injuries. There was no instance of postoperative meningitis or CSF leak. These injuries should be explored for debridement and dural repair.

Simultaneous occurrence of multiple meningiomas in different neuraxial compartments.

The simultaneous occurrence of multiple meningiomas in different neuraxial compartments is rare. A 35-year-old female patient had multiple meningiomas involving both the supratentorial compartments and in the upper dorsal spine. The patient underwent excision of 2 cranial and 2 spinal meningiomas, and has remained asymptomatic over a follow-up period of 18 months.

Retained intracranial splinters : a follow up study in survivors of low intensity military conflicts.

With improvements in the ballistic physics, patient evacuation, imaging, neurosurgical management and intensive care facilities, there has been overall improvement in the survival of patients with missile injuries of the brain. Patients with retained intracranial fragments have been followed up and the sequelae of such fragments were analysed. We present our observations in 43 such patients who had survived low velocity missile injuries of the brain during military conflicts and had retained intracranial fragments. Over a follow up period of 2 to 7 years, suppurative sequelae (brain abscess, recurrent meningitis) were seen in 6 patients, two of these progressing to formation of brain abscess. Three patients developed hydrocephalus and one seizures. Patients with orbitocranial or faciocranial wound of entry had a higher incidence of suppurative complications (3 out of 4), while those with skull vault entry had a lower incidence of such sequelae (7 out of 30). Nine patients were lost to follow up. Other determinants of suppurative complications were postoperative CSF leak and intraventricular lodgement of the fragment.

Cervical spinal cord injury without radiological abnormality in adults.

Spinal cord injury occurring without concomitant radiologically demonstrable trauma to the skeletal elements of the spinal canal rim, or compromise of the spinal canal rim without fracture, is a rare event. Though documented in children, the injury is not very well reported in adults. We present seventeen adult patients with spinal cord injury without accompanying fracture of the spinal canal rim, or vertebral dislocation, seen over seven years. None had preexisting spinal canal stenosis or cervical spondylosis. Following trauma, these patients had weakness of all four limbs. They were evaluated by MRI (CT scan in one patient), which showed hypo / isointense lesion in the cord on T1 weighted images, and hyperintensity on T2 weighted images, suggesting cord contusion or oedema. MRI was normal in two patients. With conservative management, fifteen patients showed neurological improvement, one remained quadriplegic and one died. With increasing use of MRI in the evaluation of traumatic myelopathy, such injuries will be diagnosed more often. The mechanism of injury is probably acute stretching of the cord as in flexion and torsional strain. Management is essentially conservative and prognosis is better than that seen in patients with fracture or dislocation of cervical spine.

Movement disorders caused by brain tumours.

Movement disorders are uncommon presenting features of brain tumours. Early recognition of such lesions is important to arrest further deficit. We treated seven patients with movement disorders secondary to brain tumours over a period of seven years. Only two of these were intrinsic thalamic tumours (astrocytomas) while the rest were extrinsic tumours. The intrinsic tumours were accompanied by hemichorea. Among the extrinsic tumours, there was one pituitary macroadenoma with hemiballismus and four meningiomas with parkinsonism. Symptoms were unilateral in all patients except one with anterior third falcine meningioma who had bilateral rest tremors. There was relief in movement disorders observed after surgery. Imaging by computed tomography or magnetic resonance imaging is mandatory in the evaluation of movement disorders, especially if the presentation is atypical, unilateral and/or accompanied by long tract signs.

Hypodense meningiomas.

While majority of the meningiomas can be diagnosed on contrast enhanced computerised tomography (CT) scans, few of them can have atypical appearances, which may be difficult to distinguish from those seen in glial tumours. Six atypical cases of meningioma having hypodense appearances on CT scan are described.