Post-traumatic cerebrospinal fluid leakage.

Posttraumatic cerebrospinal fluid (CSF) leakage frequently complicates skull base fractures. While most CSF leaks will cease without treatment, patients with persistent CSF leaks may be at increased risk for meningitis, and many will require surgical intervention. We reviewed the medical records of 51 patients treated between 1984 and 1998, with CSF leaks that persisted for 24 hours or longer after head trauma. Twenty-eight patients (53%) had spontaneous resolution of the leakage at an average of 5 days. Twenty-three patients (47%) required surgery. Eight patients (16%) had occult leaks presenting with recurrent meningitis at an average of 6.5 years posttrauma. Forty-three (84%) patients with CSF leaks had an associated skull fracture, most commonly involving the frontal sinus, while only 18 patients (35%) had parenchymal brain injury or extra-axial hematoma. Eight patients (16%) had delayed leaks at an average of 13 days posttrauma. Among patients with clinically evident CSF leakage the frequency of meningitis was 10% with antibiotic prophylaxis, and 21% without antibiotic prophylaxis. Thus, prophylactic antibiotic administration halved risk of meningitis. A variety of surgical approaches was used, with minimal morbidity. Three of 23 surgically treated patients (13%) required additional surgery for continued leakage. Patients with CSF leaks that persist greater than 24 hours are at risk for meningitis, and many will require surgical intervention. Prophylactic antibiotics may be effective and should be considered in this group of patients. Patients with skull fractures involving the skull base or frontal sinus should be followed for delayed leakage. Surgical outcome is excellent.

Persistent posttraumatic cerebrospinal fluid leakage.

OBJECT: Persistent posttraumatic cerebrospinal fluid (CSF) leakage frequently complicates skull base fractures. Although many CSF leaks will cease without treatment, patients with CSF leaks that persist greater than 24 hours may be at increased risk for meningitis, and many will require surgical intervention. The authors reviewed their 15-year experience with posttraumatic CSF leaks that persisted longer than 24 hours. METHODS: The authors reviewed the medical records of 51 patients treated between 1984 and 1998 with CSF leaks that persisted for 24 hours or longer after traumatic head injury. In 27 patients (55%) spontaneous resolution of CSF leakage occurred at an average of 5 days posttrauma. In 23 patients (45%) surgery was required to resolve the leakage. Eight patients (16%) with occult CSF leaks presented with recurrent meningitis at an average of 6.5 years posttrauma. Forty-three (84%) patients with CSF leaks sustained a skull fracture, most commonly involving the frontal sinus, whereas parenchymal brain injury or extraaxial hematoma was demonstrated in only 18 patients (35%). Delayed CSF leaks, with an average onset of 13 days posttrauma, were observed in eight patients (16%). Among patients with clinically evident CSF leakage, the frequency of meningitis was 10% with antibiotic prophylaxis, and 21% without antibiotic prophylaxis. Thus, prophylactic antibiotic administration halved the risk of meningitis. A variety of surgical approaches was used, and no significant neurological morbidity occurred. Three (13%) of 23 surgically treated patients required additional surgery to treat continued CSF leakage. CONCLUSIONS: A significant proportion of patients with CSF leaks that persist greater than 24 hours will require surgical intervention. Prophylactic antibiotic therapy may be effective in this group of patients. Patients with skull base or frontal sinus fractures should be followed to detect the occurrence of delayed leakage. Surgery-related outcome is excellent.

Long-term outcome of lumbar discectomy in children and adolescents sixteen years of age or younger.

We retrospectively reviewed the cases of seventy-two consecutive patients who had a lumbar discectomy, between 1950 and 1983, when they were sixteen years of age or younger. There were forty boys and thirty-two girls. At the time of the lumbar discectomy, twelve patients (17 per cent) also had a spinal arthrodesis. The mean duration of follow-up was 27.8 years (range, twelve to forty-five years). Twenty patients (28 per cent) had one reoperation or more, with the first reoperation performed at a mean of 9.7 years after the initial discectomy. Fourteen patients had one reoperation, four had two reoperations, one had three, and one had five. Fifty-two patients (72 per cent) did not need a reoperation. At the time of the latest follow-up, forty-eight (92 per cent) of the fifty-two patients either had no pain or had occasional pain related to strenuous activity and fifty-one (98 per cent) could participate in daily activities with no or mild limitations. Survivorship analysis showed that the overall probability that a patient would not need a reoperation was 80 per cent at ten years and 74 per cent at twenty years after the initial operation. With the numbers available for study, we could not show that age, gender, or an arthrodesis performed at the time of the initial operation were risk factors for a reoperation. We could not detect a difference, with respect to pain or the level of activity, between the patients who had had an arthrodesis at the initial operation and those who had not or between those who had a coexisting structural abnormality of the lumbar spine and those who did not.

Cerebellar astrocytoma: experience with 54 cases surgically treated at the Mayo Clinic, Rochester, Minnesota, from 1978 to 1990.

A comprehensive review of the literature has shown that the treatment of choice for cerebellar astrocytomas has primarily been gross-total resection of the mass and gross-total resection of the enhancing portion of pilocytic astrocytomas. Most large scale studies of postresection survival rates of patients with cerebellar astrocytomas were conducted when computerized tomography (CT) and magnetic resonance (MR) imaging were not readily available. It has been shown that postoperative CT scans or MR images are more reliable than the surgeon's estimate of the degree of tumor resection at the time of surgery. It is not possible, therefore, to make an accurate determination regarding a postresection prognosis based on the degree of suspected tumor resection without the availability of appropriate radiographic imaging. In this study, the authors retrospectively evaluated the treatment of 54 patients with cerebellar astrocytoma who underwent surgery at the Mayo Clinic in Rochester, Minnesota, from 1978 through 1990. Preoperative and postoperative CT scans or MR images were available in all 54 patients.

Spinal column deformity and instability after lumbar or thoracolumbar laminectomy for intraspinal tumors in children and young adults.

STUDY DESIGN: A retrospective study about the occurrence of spinal column deformity or instability after multilevel lumbar or thoracolumbar total laminectomy for removal of benign intraspinal tumors in children and young adults. OBJECTIVES: To analyze the long-term clinical and radiographic outcome of these patients, and to specify factors that affect the occurrence of postlaminectomy spinal column deformity and instability. SUMMARY OF BACKGROUND DATA: Spinal column deformity is not uncommon after multilevel cervical or thoracic laminectomies for removal of intraspinal tumors in children. Its incidence in the lumbar and thoracolumbar spine reportedly is low. METHODS: Thirty-six consecutive patients (23 male, 13 female) underwent multilevel lumbar or thoracolumbar total laminectomy for removal of benign intraspinal tumors from 1966 to 1989. Twelve patients were aged 17 years or younger ("children and adolescents"; mean age, 11 years), and 24 were aged 18-30 years ("young adults"; mean age, 24 years). All patients had preoperative, immediate postoperative, and follow-up clinical and radiographic examinations. RESULTS: At a mean follow-up period of 14 years (range, 4-28 years), six patients (16.6%) had spinal deformity (lordosis or thoracolumbar kyphosis associated with scoliosis), and four (11%) had spondylolisthesis. Spinal column deformity occurred in 33% of children and adolescents and in 8% of young adults. Spondylolisthesis occurred in 16.6% of children and adolescents and in 8% of young adults. Three patients had fusion for spinal column deformity. Pain was present in eight patients, and other neurologic signs and symptoms were found in 18. There was an increased incidence of postoperative spinal deformity in patients who had more than two laminae removed (P < 0.01) or a facetectomy performed at the time of the initial operation (P < 0.05). There was no association between the occurrence of the deformity and sex, neurologic condition after laminectomy, or length of follow-up period. CONCLUSIONS: Spinal deformity or instability after multilevel lumbar or thoracolumbar total laminectomy is not uncommon in children and adolescents. Limiting laminae removal and facet destruction may decrease this incidence. Fusion may be required to correct post-laminectomy deformity and to stabilize the spine.

Surgical treatment for cervical spondylitic myelopathy.

The long-term outcome of cervical spondylitic myelopathy after surgical treatment was retrospectively reviewed and critically evaluated in 100 patients with documented cervical myelopathy treated between 1978 and 1988 at our institution. Eighty-four patients were available for long-term study. The median duration of follow up was 7.35 years (range 3 to 9.5 years). There were 67 men and 17 women; their ages ranged from 27 to 86 years. The duration of preoperative symptoms ranged from 1 month to 10 years. Preoperative functional grade as evaluated with the Nurick Scale for the group was 2.1. Thirty-three patients with primarily anterior cord compression, one- or two-level disease, or a kyphotic neck deformity were treated by anterior decompression and fusion. Fifty-one patients with primarily posterior or cord compression and multiple-level disease were treated by posterior laminectomy. There was no difference in the preoperative functional grade in these two groups. The patients in the posterior treatment group were older (59 vs 55 years). There was no surgical mortality from the operative procedures; morbidity was 3.6%. Of the 33 patients undergoing anterior decompression and fusion, 24 showed immediate functional improvement and nine were unchanged. Of the 51 patients who underwent posterior laminectomy, 35 demonstrated improvement, 11 were unchanged, and five were worse. Six patients, one in the anterior group and five in the posterior group, demonstrated early deterioration. Late deterioration occurred from 2 to 68 months postoperatively. Four (12%) patients who had undergone anterior procedures had additional posterior procedures, and seven (13.7%) patients who had undergone posterior procedures had additional decompressive surgery. The final functional status at last follow-up examination for the 33 patients in the anterior group was improved in 18, unchanged in nine, and deteriorated in six. Of the 51 patients who underwent posterior decompression, 19 benefited from the surgery, 13 were unchanged, and 19 were worse at last follow up than before their initial surgical procedure. Age, severity of disease, number of levels operated, and preoperative grade were not predictive of outcome. The only factor related to potential deterioration was the duration of symptoms preoperatively. The results indicate that with anterior or posterior decompression, long-term outcome is variable, and a subgroup of patients, even after adequate decompression and initial improvement, will have late functional deterioration.

Esthesioneuroblastoma: the role of adjuvant radiation therapy.

PURPOSE: We describe our experience with adjuvant radiation therapy in patients who underwent operation for esthesioneuroblastoma. METHODS AND MATERIALS: Between January 1951 and December 1990, 49 patients with esthesioneuroblastoma received their initial treatment at the Mayo Clinic. There were 27 male and 22 female patients; their ages ranged from 3 to 79 years (median, 54 years). The tumors were Kadish Stage A in 4 patients, Stage B in 13, Stage C in 29, and modified Kadish Stage D in three (cervical nodal or distant metastasis). The tumors were graded according to Hyams' classification. Treatment included gross total resection alone in 22 patients and gross total resection and postoperative adjuvant radiation therapy in 16. The patients treated with adjuvant radiation had a greater proportion of advanced-stage and high-grade tumors. RESULTS: The 5-year actuarial overall survival, disease-free survival, and local control rates were 69.1% + 7.0%, 54.8% + 7.6%, and 65.3% + 7.4%, respectively. The only significant predictor for overall survival, disease-free survival, and local control was Hyams' grade. Local control was improved in patients who received postoperative adjuvant radiation even though this group of patients had more advanced and higher-grade tumors (5-year rate of local control was 85.9% + 9.3%, compared with 72.7% + 9.5% for those who had operation alone, p = 0.26). CONCLUSION: Adjuvant radiation therapy for esthesioneuroblastoma improves local tumor control, particularly for high-grade and high-stage tumors. We recommend additional treatment with radiation (55.5 Gy) after complete resection of esthesioneuroblastoma.

Esthesioneuroblastoma: prognosis and management.

Forty-nine patients with esthesioneuroblastoma were treated at the Mayo Clinic between 1951 and 1990. Their clinical manifestations and treatment results were reviewed to identify possible prognostic factors. The 5-year survival rate for all patients was 69%. Tumor progression occurred in 25 patients (51%; no local control in 6 and local recurrence in 19). Metastasis was found in 15 patients (31%; regional in 10 and distant in 9). Nineteen patients died directly from metastatic or intracranial tumor extension. The pathological grade of the tumor was the most significant prognostic factor identified. The 5-year survival rate was 80% for the low-grade tumors and 40% for the high-grade tumors (P = 0.0001). Surgical treatment alone is effective for low-grade tumors if tumor-free margins can be obtained. Radiation is used for low-grade tumors when margins are close, for residual or recurrent disease, and for all high-grade cancers. The poor prognosis associated with high-grade tumors may also mandate the addition of chemotherapy. Recurrent tumor and regional metastasis should be treated aggressively because this approach has been shown to be worthwhile. A craniofacial resection is now the surgical procedure performed in all cases. Because recurrence can occur after 5 or even 10 years, long-term follow-up is mandatory.

Long-term results of spinal accessory nerve-facial nerve anastomosis.

A number of methods have been developed to reduce the cosmetic and functional disability resulting from facial nerve loss. It has often been suggested that the major trunk of the spinal accessory nerve should not be sacrificed for providing dynamic facial function because of shoulder disability and pain. A review of Mayo Clinic records has revealed that, between the years of 1975 and 1983, 25 patients underwent spinal accessory nerve-facial nerve anastomosis using the major division (branch to the trapezius muscle) of the spinal accessory nerve. There were 11 males and 14 females, ranging in age from 16 to 60 years (mean 41 years). The interval between facial nerve loss and anastomosis was 1 week to 34 months (mean 4.62 months). The duration of follow-up study ranged from 7 to 15 years (mean 10.8 years). Twenty patients had no complaints or symptoms related to their shoulder or arm at the time of this review and no patient had significant shoulder morbidity. The facial function achieved was "minimal" in five cases, "moderate" in six, and good to excellent in 14. Most patients appeared to benefit significantly from the spinal accessory nerve-facial nerve anastomosis. The morbidity of the procedure seemed quite minimal even in the young and active. The authors continue to believe that the spinal accessory nerve-facial nerve anastomosis, even when using the major trunk of the spinal accessory nerve, is a very useful and beneficial procedure.

Current results of the retrosigmoid approach to acoustic neurinoma.

Since 1984 when cranial nerve monitoring became routinely performed at the Mayo Clinic, 255 patients have undergone 256 procedures using the retrosigmoid approach for the removal of acoustic neurinomas. Of these, 221 patients had some hearing before surgery and 52 maintained hearing following surgery. The anatomical continuity of the facial nerve was preserved in 237 of these 256 procedures. It was possible to perform a primary end-to-end anastomosis in seven of the remaining 19 patients, and one patient had a cable graft inserted. Thus, 95.7% of these patients were believed to have potential for spontaneous facial nerve function. Of the 11 patients in whom this was not possible, seven underwent early spinal accessory facial anastomosis, in two hypoglossal-facial anastomosis was performed, and two had no facial nerve procedures and have paralysis of the facial nerve. There were two deaths from a pulmonary embolus in the early postoperative period, both 4 days following otherwise uneventful surgery. The most common postoperative complication was cerebrospinal fluid leakage, which has not resulted in significant permanent morbidity although early repair for this problem is now routinely recommended. Other complications were quite rare and have generally not resulted in any major change in patient lifestyle or activity level. This review reconfirms that the retrosigmoid surgical treatment of acoustic tumors continues to be an acceptable treatment option.

Iopamidol myelography: morbidity in patients with previous intolerance to iodine derivatives.

The records of 1005 patients who underwent iopamidol myelography between January and September, 1988, were reviewed. In this group, 50 patients had histories suggestive of untoward sequelae associated with iodine intake, contact, or administration. The charts of these patients were carefully reviewed, and none of them had any reactions or sequelae suggestive of toxicity or an allergic response after iopamidol myelography. It is concluded that, even in patients with a previous history suggestive of intolerance to iodine administration, iopamidol myelography is generally a safe procedure.

Surgery of spinal nerve schwannoma. Risk of neurological deficit after resection of involved root.

When surgically removing a spinal nerve schwannoma, preservation of the involved root is attempted and may be feasible. However, in large tumors, sacrifice of the nerve root is often required to achieve total removal of the tumor, and the resection does not always result in postoperative neurological deficit. The present study was designed to determine the incidence and extent of neurological deficit as correlated with resection of the root, performed between 1976 and 1987 in 86 cases at the time of total removal of spinal schwannoma. Thirty-one patients underwent sacrifice of a root critical for the function of the upper (C5-T1, 14 cases) or the lower extremities (L3-S1, 17 cases). This report is limited to these 31 cases. Only seven patients (23%) developed detachable motor or sensory deficits postoperatively. All deficits were no more than partial loss of strength or sensation. Fifteen of the 31 patients had large tumors with extradural components, which necessitated sacrifice of the entire motor and sensory radix; however, 11 (76%) of these 15 did not develop any deficits referrable to the involved myotome or dermatome. Six cases showed histological characteristics of "neurofibroma," with axons intermingled in the tumor, and none developed a postoperative deficit. Preoperative electromyography was performed in 23 cases. Of 13 patients with findings of denervation, five developed deficits after surgery; the other 10 patients showed no evidence of denervation, and none had deficits after surgery. These results indicate that the spinal roots giving origin to schwannoma are frequently nonfunctional at the time of surgery, and risks of causing disabling neurological deficit after sacrificing these roots are small.

Choroid plexus papillomas: long-term follow-up results in a surgically treated series.

The medical records and histological specimens from 26 patients with choroid plexus papillomas operated on at one institution were reviewed retrospectively. Four patients died perioperatively, and 21 of the remaining 22 patients were followed through March, 1986; the patient lost to follow-up review was last seen 14 years postoperatively. Of the 14 patients who underwent gross total removal of their tumor, one had a recurrence at 11 years postoperatively and two died in the perioperative period. Of the 12 patients who underwent subtotal removal of their tumor, two died in the perioperative period. The two patients who did not have radiation therapy postoperatively are free of apparent disease at 6 and 8 years after their operation. Eight patients underwent radiation therapy after subtotal removal of their tumor; four of these remain alive and well, and four have died of progressive disease. The role of irradiation in the treatment of subtotally resected lesion remains controversial, but this therapy is thought to be indicated for recurrent disease after a surgical excision that is as complete as possible. Histopathologically, the presence of occasional mitotic figures, microscopic infiltration, ependymal differentiation, or mild to moderate atypia was not correlated with likelihood of complete resectability or tendency to recurrence.

Results of lumbar discectomy in the pediatric patient.

To determine the results of lumbar discectomy in pediatric patients, a review was conducted of the medical records of 74 consecutive patients (40 males and 34 females) younger than 17 years who underwent lumbar disc surgery between 1950 and 1983. During this period, only 3% of patients younger than 17 years who presented with the chief complaint of low-back pain eventually had lumbar disc operation. In 43 patients it was thought that an injury had precipitated the symptoms. Thirty-seven patients had a nerve deficit at the time of initial evaluation. Water-soluble contrast myelography with repeated postmyelographic computerized tomography is currently used to confirm the diagnosis. The disc operations were performed at the L4-5 level in 47% of patients, the L5-S1 level in 45%, the L3-4 and L4-5 level in 4%, and the L4-5 and L5-S1 level in 4%. Fourteen of the 74 patient underwent spinal fusion with their first operation. At 9 months postoperatively, 95% had good or excellent results. During an extended follow-up period of up to 34 years, 16 of the patients with early successful results required further back procedures. After all medical and surgical treatment in this group of patients, the results were excellent in 57%, good in 38%, and poor in only 4%.

Thoracic disc disease: diagnosis and surgical treatment.

Symptomatic thoracic disc disease is uncommon. Unlike cervical or lumbar disc disease, this disorder frequently is not associated with pain. Often, diagnosis is delayed until signs of myelopathy develop. Surgical intervention is the treatment of choice. Because of the unique characteristics of the thoracic spinal canal, the vascular supply to the spinal cord, and the fact that many of these disc extrusions are anterior to the cord, different surgical techniques are needed. Few patients experience intraoperative complications; however, some approaches predispose patients to the risks of both thoracotomy and exploration of the spinal canal. Postoperative complications are similar to those associated with thoracotomy. Most patients have an improvement in neurologic function after therapy.

Long-term results in transsphenoidal removal of nonfunctioning pituitary adenomas.

Little has been written about the long-term results of transsphenoidal treatment for clinically nonfunctioning pituitary adenomas. The records of 100 patients who had undergone a transsphenoidal procedure for excision of such tumors were reviewed. Immunocytology for pituitary hormones was performed in all cases. The group consisted predominantly of null-cell adenomas, although a small number of prolactinomas and gonadotropic tumors were found. The mean diameter of the tumors at the time of detection was slightly more than 2 cm. In most cases, the presenting symptoms were due to the mass effect of the tumor (that is, visual symptoms in 72 patients, hypopituitarism in 61, headache in 36, and cranial nerve disturbance other than visual loss in 10). Radiation therapy was recommended for patients in whom subtotal removal of the adenoma was expected. Six patients developed symptomatic tumor recurrence, and 10 patients demonstrated radiographic recurrence during the 48 to 100 months (mean 73.4 months) of follow-up observation. Only three of 10 deaths during the follow-up period were due to pituitary disease or treatment.