Ventriculo-atrial shunt via the left axillary vein--a novel approach.

This report describes a technique to divert cerebrospinal fluid into the right atrium via the left axillary vein in a patient in whom other methods had been attempted without success.

Results of posterior cervical foraminotomy for treatment of cervical spondylitic radiculopathy.

We evaluated the results of posterior cervical foraminotomy for spondylitic radiculopathy using a questionnaire sent to all 77 patients who had undergone surgery between 1990 and 1995 at our institution. Sixty-two patients (40 male) returned their questionnaires, one of whom had undergone two procedures (dealt with as separate events). Sixty patients complained of pre-operative arm pain; of these 42 (70%) had complete or > 75% resolution of their pain, 14 (23%) had < 75% improvement in their pain and four (7%) had the same or worsened pain at the time of the questionnaire. Sixteen patients (27%) reported initial improvement in symptoms with subsequent deterioration. The mean patient satisfaction score using a linear analogue scale from 0 to 10 was 7.5. Main postoperative complaints were neck pain (22%), persisting motor deficit (6%) and persisting sensory deficit (9%). One patient suffered nerve root damage at surgery. For unilateral and, in some cases, multi-level degenerative disease causing cervical radiculopathy, posterior cervical foraminotomy is a useful technique with the advantage of avoiding fusion, immobilization and the long-term risk of instability.

Posterior fossa meningiomas: surgical experience in 52 cases.

BACKGROUND: Early reports of the surgical management of posterior cranial fossa meningiomas (PCFM) yielded poor results with high rates of mortality and morbidity. With the advent of modern neuroimaging and microsurgical techniques the results of surgery have improved markedly, but despite these advances removal of these lesions remains a challenge. METHODS: The results of the surgical treatment of PCF meningiomas were examined with the aim to identify particular features associated with increased mortality and morbidity. RESULTS: Of 713 patients with meningioma, 52 patients were identified with PCFM. Total macroscopic excision was achieved in 44 patients (84%). Postoperative complications occurred in 28 patients (54%) with permanent sequelae in 18 (35%). There were no mortalities in the immediate postoperative period. Follow-up ranged from 14 to 174 months (mean 42), tumour has recurred in 11 patients (21%) with a long-term mortality of 11%. At their latest follow-up 41 (79%) of patients achieved Glasgow outcome scores of 4 or 5. CONCLUSIONS: Total excision of tumour should remain the goal of treatment in patients with PCFM. Despite the recent advances in preoperative planning and surgical techniques, the morbidity associated with surgery remains significant. Notwithstanding, the majority of patients achieve a good outcome with surgical treatment.

Endoscopic removal of a third ventricular cysticercal cyst.

We report the case of a young man who presented with acute obstructive hydrocephalus previously treated with bilateral ventriculo-peritoneal shunts. Previous magnetic resonance imaging studies were consistent with aqueduct stenosis; no intraventricular pathology was identified. Neuroendoscopy was performed in order the third ventricle and perform a third ventriculostomy. This revealed a cysticercal lesion of the third ventricle which was removed endoscopically. In addition, a third ventriculostomy was performed and both shunt systems removed. Following a course of albendazole the patient went on to make a full recovery, and currently remains shunt independent.

Neurenteric sinus dorsal to the thoracic spine with an associated cutaneous haemangioma: case report.

The case of an infant born with a large cutaneous haemangioma overlying the thoracic spine is presented. A small midline pit lay within the haemangioma, histological examination of which confirmed it to be a neurenteric sinus. The possible embryological origins of this rare lesion are discussed.

Comparison of rates of infection of two methods of emergency ventricular drainage.

The rates of infection of two methods of external ventricular drainage in use at Atkinson Morley's Hospital--namely, (a) percutaneous drainage with Rickham reservoirs and (b) tunnelled ventriculostomies--were compared in this retrospective review. Percutaneous drainage of CSF with Rickham reservoirs was associated with a 27% rate of infection as identified by positive microbiological cultures; tunnelled ventriculostomy catheters had a 10% infection rate. The difference in the infection rate between the two methods was statistically significant (P < 0.015). Other variables examined, including the age and sex of the patients and the reasons for ventricular drainage, were not associated with an increased rate of infection. Most infections from either method were caused by a coagulase negative staphylococcus. The average duration of ventricular drainage before identification of positive cultures was 5.7 days for Rickham reservoirs and 6.0 days for ventriculostomies.

Adult postrepair myelomeningocoele and tethered cord syndrome: good surgical outcome after abrupt neurological decline.

Adults who have had repair of an open myelomeningocoele at birth are susceptible to a variant of adult onset tethered cord syndrome (ATCS). Precipitous and profound loss of lower extremity motor function occurred in two postrepair adult patients, but was not seen in any of our 12 cases of adult tethered cord with any other aetiologies. Both postrepair ATCS patients made a good recovery after surgical release of the tether. For the patients with other aetiologies, surgery yielded improvement or recovery of urinary continence in 57%, relief from pain in 78% and improved strength in 80%. Evidence of retethering was observed in 25% of the operated patients at intervals ranging from 1 to 9 years postoperatively. We conclude that surgical release of tether can reverse incontinence in ATCS of any aetiology and that in the post-myelomeningocoele repair patient, both dexamethasone and surgical intervention are helpful in reversing acute neurological deterioration.

Intracranial aneurysm formation following radiotherapy.

Two patients sustained a subarachnoid haemorrhage secondary to radiation-induced vasculopathy and associated aneurysm. A 65-year-old woman was treated by radiotherapy for a stereotactically biopsied left parieto-temporal astrocytoma. Three-and-a-half years later, she suffered a subarachnoid haemorrhage secondary to a giant aneurysm arising from the middle cerebral artery bifurcation. A 44-year-old man sustained a subarachnoid haemorrhage 21 years after receiving whole brain irradiation for a large left parietal angioma. Angiography following his subarachnoid haemorrhage revealed a distal right middle cerebral artery aneurysm that was not visible on earlier angiograms. Both patients underwent craniotomy for their aneurysms with good postoperative recoveries.

Is peroperative smear cytology necessary for CT-guided stereotaxic biopsy?

Neuropathology is a relatively scarce resource with uneven geographical distribution, and some surgeons rely on macroscopic appearances of tissue and await later paraffin section histology for the final diagnosis. The effect of the introduction of a peroperative cytology service has been assessed in a 5-year series of CT-directed stereotaxic biopsies of intracranial mass lesions using a low cost adapted pre-CT stereotaxic frame. The technique has been mastered by 28 different surgeons with varying degrees of neurosurgical expertise and 259 procedures have been performed in 245 patients. Benign lesions were detected in 24 (9.8%) patients, confirming the importance of making a histological diagnosis prior to initiating treatment. Permanent morbidity was 6.5% and mortality 3.3% and morbidity was balanced by an improvement in 19.6% of the patients following the procedure. For the first 142 patients no peroperative histological diagnosis was available and a diagnostic rate of 86.6% was achieved. For the last 103 patients the availability of peroperative smears improved the diagnostic rate to 94.2% and reduced the number of second biopsies needed for diagnosis from seven to zero. Our series demonstrates the need for peroperative cytology in CT stereotaxic biopsies, and confirms that a complete neuropathology service is a prerequisite for neurosurgical patient care.

Cortical mapping and local anaesthetic resection as an aid to surgery of low and intermediate grade gliomas.

We report four cases of the use of peroperative cortical mapping during craniotomy under local anaesthesia to define the relationship between the glioma and speech and somatosensory cortex. This enabled a radical subtotal (two cases) or an apparent total (two cases) excision of the tumour close to the somatosensory and speech cortex with no permanent neurological deficit. Use of this technique allows radical excision of intrinsic low and intermediate grade gliomas that would otherwise be considered unexcisable and may lead to an improved survival.

Improved access to lesions of the central skull base by mobilization of the zygoma: experience with 54 cases.

Improved access to lesions at the medial end of the sphenoid wing or in the interpeduncular cistern after mobilization of the zygoma has been a subject of growing interest in recent years. This study describes the operative technique we have adopted and records our experience with 55 operations in 54 patients who underwent the procedure in the past 3 years. Seven patients had vascular lesions, 44 had tumors, and 3 had miscellaneous lesions. The majority of the tumors were medial meningiomas, and particular note is made of those arising from the cavernous sinus with respect to their resectability. Sixteen of these tumors were encountered, and total excision was possible in 11 cases. Access to the infratemporal fossa is facilitated, and in 2 cases we were able to excise completely trigeminal neuromas that had extended there. The extra maneuver adds little to the overall operating time, and complications relating to it are uncommon, mild in degree, and usually self-limiting. We conclude that the operation is extremely valuable in appropriate circumstances.

Tuberculosis of the skull--a rare condition: case report and review of the literature.

A 25-year-old woman exhibited swelling of the scalp and a bony defect of the skull from which Mycobacterium tuberculosis was cultured. The case is reported, and the literature is reviewed.

Craniocervical stabilization using Luque/Hartshill rectangles.

Untreated craniocervical instability is associated with a high morbidity and a significant mortality. Existing methods using bone grafts, interlaminar wires, or acrylic eventually produce stability but require prolonged periods of immobility and have a high failure rate. The ideal method of fixation should provide for permanent correction of deformity and relief of symptoms, with immediate stabilization, at a single procedure. Posterior fixation of the occiput to a stable part of the cervical spine with a molded metal rectangle held in place by interlaminar wires was used to accomplish this. We report 20 patients treated consecutively who have undergone craniocervical fusion by this method using Luque/Hartshill rectangles. Fourteen patients had preexisting atlantoaxial instability and 6 had cord compression, but would become unstable after decompression. All operations were performed under general anesthesia; 9 patients (40%) were awake for intubation/positioning, and 7 patients had a simultaneous decompression. Sixteen patients made an uncomplicated recovery and became mobile 3 days postoperatively. Symptomatic and neurological improvement occurred in 70% of all patients. Neurological complications occurred in 4 patients (20%), reflecting the serious nature of the condition; 2 patients (10%) showed no change. Scrutiny of their presentations and operations failed to identify avoidable risk factors, except faulty wiring techniques. In all patients, permanent stabilization was achieved immediately, facilitating early mobilization with a real chance of improvement, which indicates that the method merits wider application.

A scale for neurosurgical audit.

A neurosurgical audit scale has been devised to provide a measure of disability and outcome. The audit scale was tested for observer variation and sensitivity against the Karnofsky scale, the Rosser disability scale and the Rosser distress scale. The highest ratio of observer concurrence compared with chance was noted for the neurosurgical audit scale, and the lowest ratio for the Rosser distress score. Sensitivity was almost identical for each of the scales. The neurosurgical audit scale lends itself to audit based on a computer database for which the input is the discharge summary. This achieves audit without additional work for either medical or secretarial staff.

Cortical mapping and resection under local anaesthetic as an aid to surgery of low and intermediate grade gliomas.

We report four cases of the use of per-operative cortical mapping during craniotomy under local anaesthesia to define the relationship between the glioma and speech and somatosensory cortex. This enabled a radical subtotal (two cases) or an apparent total (two cases) excision of the tumour close to somatosensory and speech cortex with no permanent neurological deficit. Use of this technique allows radical excision of intrinsic low and intermediate grade gliomas that would otherwise be considered unexcisable and may lead to an improved survival.

Synchronous vertebral decompression and posterior stabilization in the treatment of spinal malignancy.

Thirty-four patients with metastatic tumors of the spinal column exhibiting vertebral collapse and posterior element disease were treated by a single-stage operation combining decompression of the vertebral body with posterior spinal instrumentation. Attention is drawn to the use of computed tomographic scanning in planning the operative approach. The indications for surgery were neurological deficit in 32 patients and pain in 2; 14 patients received preoperative radiotherapy. Of the 21 patients who were nonambulant preoperatively, 67% walked again, 21% regained sphincter control, and 68% had less pain. The surgical mortality was 12%; wound infection and dehiscence occurred in 15%. These results indicate that a single-stage decompression and posterior stabilization may improve neurological function dramatically in patients with malignant cord compression. The operative morbidity and mortality is comparable to that of laminectomy.

Chemotherapy as the initial treatment of spinal cord compression due to disseminated neuroblastoma.

During a 12-month trial period, all children attending the Hospitals for Sick Children, London, England, for management of spinal cord compression due to disseminated neuroblastoma were given chemotherapy as initial treatment rather than radiotherapy or laminectomy. Response to treatment was evaluated by a neurosurgeon as well as by oncologists. Four children were treated in this way and all made a full recovery of spinal cord function.

A low cost system for performing CT stereotaxic brain biopsy.

The cost of commercially available CT-compatible frames for stereotaxic brain biopsy has limited their availability in the U.K. Our adaptation to a pre-CT stereotaxic frame that had been in use at Atkinson Morley's Hospital for 12 years, and the availability of a GE 9800 CT scanner has allowed us to carry out accurate CT-directed stereotaxic biopsy at minimal cost. The system has the additional advantage of speed and ease of use in inexperienced neurosurgical hands. Biopsies in 100 patients have been performed by 12 different surgeons (80% by registrars) who mastered the technique without difficulty. The rates of permanent morbidity (4%) and mortality (2%) are low, the two mortalities occurring in patients with high grade astrocytomas. They compare very favourably with rates for freehand burr-hole biopsy, and our overall diagnostic success rate of 83% for the initial biopsies, rising to 90% as a result of re-biopsy in 10 of the patients, is similar to that achieved with much more costly commercial systems. Benign lesions were found in 7% of patients who would otherwise have been assumed to have malignant tumours, and this finding emphasises the value of achieving a histological diagnosis in every lesion of the brain.

Priapism as a feature of claudication of the cauda equina.

A case is reported of a man 60 years of age with degenerative stenosis of the lumbar canal at the L3-4 level and lumbar arachnoiditis, whose symptoms of claudication of the cauda equina were accompanied by uncomfortable involuntary erections. All symptoms were relieved by surgical decompression.