Supratentorial neurenteric cyst associated with a intraparenchymal subependymoma.

Neurenteric cyst is a rare developmental lesion that very infrequently is localised supratentorially. Intraparenchymal subependymoma is an even more rare benign tumour. The authors report the case of a 45-year-old gentleman with a background of drug resistant epilepsy. An MRI was performed which showed a left frontal cystic lesion with a solid component. Histopathology confirmed a type C neurenteric cyst associated with an intraparenchymal subependymoma. Following enlargement of the lesion and worsening of symptoms he was referred to our institution for further management. A frontotemporal craniotomy was performed for excision of the lesion but recurrence occurred within 1 year. The lesion was further excised and 19 months post re-excision the patient is seizure free with no evidence of recurrence on MRI.

Favourable long-term clinical outcome after anterior cervical discectomy. A study on a series of 125 patients undergoing surgery a mean of 11 years earlier.

OBJECTIVE: This retrospective study assessed long-term clinical outcome in a series of patients undergoing anterior cervical discectomy (ACD) for treatment of myeloradiculopathy secondary to one- to two-level cervical discoarthrosis. To verify concerns about long-term adverse clinical effects following ACD, a review of literature on the topic was also made. METHODS: The clinical course and long-term outcome of 125 consecutive patients with cervical myeloradiculopathy operated on by ACD 5 to 19 years ago (mean, 11.3 years) were reviewed. Seventy-four patients (59%) showed a clinical picture of pure radiculopathy, and 51 patients (41%) had myeloradiculopathy. Long-term clinical outcome and Visual Analog Scale (VAS) scores for neck and arm pain were recently assessed and compared with post-surgical status. Clinical outcome was graded according to the criteria of Odom et al. (JAMA 166:23-28, 36). The survey of the literature on long-term clinical outcome after ACD was internet-based. RESULTS: Long-term clinical outcome was excellent in 61% of patients, good in 26%, satisfactory in 9% and poor in 4%. The same figures at the time of discharge were 65%, 29%, 6% and 0%, respectively. Mean long-term neck and arm pain VAS scores were 2.5 and 0.8, respectively, while postoperatively, the same values were 2.1 and 0.5. Additional discectomy at an adjacent level was performed in five patients 10 months to 8 years after the first operation. CONCLUSIONS: In our series, 96% of patients had a sustained favourable long-term clinical outcome after ACD. These favourable results confirm data in the literature and support our preference for ACD as the simplest, fastest and cheapest surgical option for treating myeloradiculopathy secondary to one- to two-level cervical discoarthrosis.

Microsurgery for recurrent lumbar disk herniation at the same level and side: do patients fare worse? Experience with 95 consecutive cases.

BACKGROUND: In reviewing our experience with reoperation of RLDH, our aim was mainly to determine whether patients fared worse than after primary surgery. We found no uniform answers to this question in the literature. METHODS: The data of 95 patients (29 women and 66 men) who underwent reoperation for RLDH at the same level and side were analyzed retrospectively. Forty-two patients underwent the first operation in our clinic (recurrence rate, 2.6% of 1586 cases). Gadolinium-enhanced MRI was performed in all patients. Main clinical data of patients, pain-free interval, operation time, surgical complications, duration of hospital stay, and clinical improvement rate were recorded. RESULTS: The mean pain-free interval was 55 months (range, 3-120 months). Levels of recurrent herniation were L4 through L5 and L5 through S1 (65% and 35% of cases, respectively). Revision surgery lasted longer on average than the previous diskectomy (P < .01) and was complicated by dural tear in 4 cases (4.2% vs 0.9% during primary diskectomy, P < .05). There were no significant differences between revision and previous surgery in terms of hospital stay. However, rates of excellent/good outcomes were significantly less for RLDH (89% vs 95%, P < .05); and the percentage of poor results was higher (2% vs 0.5%, P < .05). Age, sex, smoking, profession, trauma, level and degree of herniation, and pain-free interval were not correlated with clinical outcome. CONCLUSION: Conventional microsurgery for RLDH showed lightly but significantly worse results than those of primary microdiskectomy. Patients contemplating reoperation should be informed of this fact and of the risk of dural tear and prolonged operation time.

Cervical spine epidural abscess: experience with microsurgical treatment in eight cases.

OBJECT: The authors report a series of eight consecutive cases in which epidural abscesses in the cervical spine were treated by microsurgery without arthrodesis, including two cases of concomitant pyogenic and tubercular infection. METHODS: The authors used a minimally invasive surgical approach consisting of single-level anterior microsurgical discectomy and drainage of the epidural abscess via a silicone catheter, and then initiated antibiotic therapy. At follow-up examination (mean duration 39 months), six patients exhibited complete recovery and two suffered from minor residual deficits. In all cases, spontaneous vertebral fusion occurred. Sagittal alignment was maintained in seven patients, and in one there was slight asymptomatic kyphosis. In two patients, tubercular and pyogenic infections were found. Prior intervention for dental infection was recorded in four cases. CONCLUSIONS: In the absence of preoperative spinal instability, microsurgical drainage of the abscess followed by specific antibiotic therapy resulted in spinal cord decompression and neurological recovery, thereby facilitating spontaneous fusion and vertebral stability. The presence of combined tubercular and pyogenic infections of the cervical spine should be considered, especially in patients whose immune systems are depressed.

Vagus nerve stimulation for drug-resistant epilepsy in children and young adults.

We present our experience with the use of intermittent vagal nerve stimulation in 13 patients with medically intractable epilepsy. A surgical approach, with the exception of callosotomy, was impossible. The age range was 6-28 years (median 17 years). In all patients the epilepsy was severe and in six of them was symptomatic. Seven patients had Lennox-Gastaut syndrome, one epilepsy with myoclonic-astatic seizures, four localization-related and one symptomatic generalized epilepsy. The length of the follow-up averaged 22 months (range 8 months-3 years). Of the 13 patients, five (38.4%) had a 50% or more reduction in the number of seizures compared with preimplantation. Of these patients, one with a localization-related epilepsy had a 90% reduction as well as a significant improvement in alertness. Three patients showed no improvement with regard to the number of seizures but there was an improvement in alertness and, in one case in hyperactivity. Some seizure types responded better than others did: complex partial seizures with secondary generalization and atonic seizures. All our responsive patients improved in the first 2 months of VNS activation and only one case with further improvement was observed after this period. Considering the severity of the epilepsy the results can be considered satisfactory. We think that this treatment appears to be a safe adjunctive therapy for children and adults with medically and surgically intractable epilepsy.