Recruitment curve of the soleus H-reflex in chronic back pain and lumbosacral radiculopathy.

BACKGROUND: Needle EMG may be negative in mild or predominantly sensory lumbosacral radiculopathies. In such cases, an increase in the latency of the soleus H-reflex is a useful diagnostic criterion for establishing sensory fiber compromise at the S1 root level. However, if clinical signs of radicular involvement are lacking, the latency of the H-reflex is normal. We therefore studied the recruitment curve of the soleus H-reflex to investigate whether a change in the electrical threshold for eliciting the H-reflex might be a more sensitive criterion for detecting subclinical S1 root dysfunction. METHODS: Clinical and electrophysiological findings from 26 patients with chronic back pain and radiculopathy were compared with data obtained from 40 healthy subjects. RESULTS: An increase in the mean H-reflex threshold was the only abnormal electrophysiological finding in patients with no clinical sign of root injury (58%). A decrease in the mean H-reflex amplitude and a prolongation of H-reflex latency was observed in patients with radicular signs (42%). In both patients groups, F-wave and needle EMG studies were normal. No radiological evidence of S1 root compression was found. CONCLUSIONS: The study of the recruitment curve of the soleus H-reflex may be usefully associated to F-wave and needle EMG studies to detect possible S1 root dysfunction in mild lumbosacral radiculopathies. An increase in H-threshold may be the earliest abnormality in the absence of focal neurological signs.

Abnormalities of the soleus H-reflex in lumbar spondylolisthesis: a possible early sign of bilateral S1 root dysfunction.

Using routine electrodiagnostic procedures, the authors searched for physiologic evidence of nerve root compromise in patients with chronic mechanical perturbation to the lumbar spine. They examined 37 patients with spondylolisthesis and various degrees of degenerative changes in the lumbar canal. Clinical and neurophysiologic findings were compared with data obtained from 36 healthy persons. The soleus H-reflex appeared to be a sensitive indicator of sensory fiber compromise at the S1 root level, because changes correlated well with the focal sensory signs and preceded clinical and electromyographic signs of motor root involvement. When these occurred, the clinical findings were consistent with a more severe nerve root deficit and with radiographic evidence of neural compression. The greater sensitivity of the soleus H-reflex may be related to the pathophysiologic events that occur at the lesion site.

Posterior retroextramarginal disc hernia (PREMDH): definition, diagnosis, and treatment.

BACKGROUND: Detachment of the posterior part of the lumbar vertebral ring apophysis has been reported by many authors, associated or not with disc prolapse, and has been ascribed to various mechanisms, although the relationship between the two pathologies remains unclear. METHODS: We studied 26 patients (17 males and 9 females; mean age, 34.3 years) suffering from a lumbar disc herniation with nontraumatic detachment of the ring apophysis. Investigations included standard X ray, computed tomography (CT), tridimensional CT, and magnetic resonance imaging. Nineteen patients were operated on by microsurgical discectomy and removal of bone fragments. RESULTS: Clinical and neuroradiologic features of herniated disc associated with detachment of the ring apophysis have been recognized and have led to the definition of posterior retroextramarginal disc herniations. A further classification is suggested, considering two morphological types that imply clinically distinctive features and a different surgical approach. In all operated cases, removal of the bone fragments was necessary and the results were good. CONCLUSIONS: Our observations led us to postulate a common mechanism in the pathogenesis of disc herniation with nontraumatic detachment of the ring apophysis. They should be distinguished from other calcifications of the disc because a proper surgical technique, including removal of apophyseal fragments, is required.

Neurinoma of the cauda equina misdiagnosed as prolapsed lumbar disk. Report of three cases.

The authors report three cases of neurinoma of the cauda equina initially misdiagnosed as prolapsed lumbar disk. Computed Tomography failed to reveal the tumour, while showing evidence of disk-degenerative patology and being thus misleading. Similar cases are reported in literature. After a thorough analysis of the causes of such an apparently gross error, it is concluded that the main source of pitfalls arises from neglecting those typical clinical features differentiating prolapsed disk from oncogenetic sciatica. When oncogenetic sciatica is suspected Computed Tomography is inappropriate and even misleading, while the elective investigation is Magnetic Resonance.

Oculocerebral perforating trauma by foreign objects: diagnosis and surgery.

Two unusual cases of perforating oculocerebral trauma by foreign bodies treated surgically are reported. Both were caused by industrial accidents. In the first a nail shot from a nail gun ricocheted off the target and crossed the right eyeball and the posterior wall of the orbit, lodging in the homolateral temporal lobe. In the second case a metal fragment expelled by an agricultural machine penetrated the left maxillary sinus, crossed the floor of the orbit, the eyeball and the roof of the orbit and lodged in the homolateral frontal lobe. After accurate neuroradiological examination the patients were operated using simultaneous transcranial and transorbital access. In our opinion this is the only approach which can minimize the risk of infection which is so dangerous in this type of trauma. The functional and aesthetic results, which were very satisfactory in both cases, seem to confirm the correctness of this approach.

Growing skull fractures: progressive evolution of brain damage and effectiveness of surgical treatment.

The growing skull fracture of childhood is a well-known but variously interpreted syndrome. Attempts have been made to find different pathogeneses for clinical and pathological patterns that are really successive phases of a single process, arising from the interaction of three basic conditions: (1) head injury with a large gaping fracture; (2) corresponding dural tear; (3) occurrence nearly always in infancy (the first year of life or period of maximum brain growth). This combination of factors alters the normal distribution of the intracranial pressure vectors and the fracture behaves like a "neosuture" with abnormal growth of the skull on the injured side. Simultaneously, the ventricular system tends to deform, dilating and shifting towards the side of the fracture. Three cases, successfully treated at a very late stage, are described. The good surgical results confirm the validity of the surgical method and its underlying theoretical basis.

[Cerebral venous angiomas in childhood]. / Angiomi venosi cerebrali nell'infanzia.

Six cases of cerebral venous angioma in children under 8 years of age reported, with respects to their clinical and neuroradiological features. Any attempt of classification is inadequate, due to the protean characteristics of these malformations, wich can be definied - and usually are - upon the base of predominantly angiographic standards, a valuable diagnostic help being provided by the computerized tomographic investigation. The study of cerebral regional blood flow can represent a major instrument when the clinical and morphological aspects of the malformation make an alteration of it suspectable. In the cases we operated on, clinical healing has been obtained; no worsening has been observed in non-operated cases, during a follow-up of 1 to 7 years; only one of our little patients, presenting with an enormous aneurism of Galen's vein, which we regarded as inoperable, died at 9 months of age.

Cerebral venous angioma, cutaneous angioma, facial asymmetry and recurrent stroke. A case report.

The case of an 8-year-old boy presenting diffuse, prevalently right-sided nevus flammeus, venous angioma of the right cerebral hemisphere, right-sided facial hyperplasia, lef-handedness and recurring strokes is reported together with the clinical, angiographic and CT features.

[Treatment of trigeminal neuralgia using controlled differential selective thermorhizotomy]. / Trattamento della nevralgia del trigemino mediante termorizotomia selettiva differenziale controllata.

Personal experience in 35 cases of controlled, partial, selective thermorhizotomy of the trigeminus is referred to in a discussion of its indisputable advantages (abolition of pain, preservation of tactile sensibility, simple method) by comparison with other techniques, and its theoretical basis: selective lesion of the "delta" A and C fibres by exploiting the vulnerability gradient of the nerve fibres to heat.

Trigonocephaly: some clinical and surgical features.

Trigonocephaly is a partial form of craniostenosis or rather craniofaciostenosis in which the esthetic damage is severe and early and in which the functional damage (mental retardation, strabismus) may also be severe. The former can be corrected and the latter prevented by early and appropriate surgery. A new surgical procedure for correcting uncomplicated trigonocephaly permits normal development of the skull and orbits and normal psychomotor development.

Supratentorial hemangioblastoma in childhood.

Only 2 cases of supratentorial hemangioblastoma in children are recorded. We report a third: an occipital cerebral hemangioblastoma in a 9-year-old girl. The tumor had a solid subpial portion continuous with a cystic intraparenchymal portion. It had no dural insertion, although it was in contact with the falx. A year after complete removal there is no sign of recurrence.

[Hydrocephalus and craniodiaphyseal dysplasia (author's transl)]. / Idrocefalo associato a displasia cranio-diafisaria.

One case is reported of dilatation of the lateral ventricles in a patient suffering from craniodiaphyseal dysplasia, with follow up of one year. The pathogenic hypothesis personally proposed are: a) partial and intermittent compression of the aqueduct by a dolico-mega basilar artery; b) "cisternal hypofunction".

Contribution to the study of craniostenosis: disturbance of the cerebrospinal fluid flow in oxycephaly.

In 6 cases of oxycephaly, isotope (RIHSA) cisternography showed an altered CSF circulation with ventricular reflux or cisternal block and accumulation of the contrast at lumbosacral level. These changes express increased absorption of the CSF by the spinal arachnoid villi to compensate for reduced or nonexistent absorption by the subarachnoid villi of the vault, obstructed by chronic intracranial hypertension secondary to craniosynostosis. The possible clinical implications are outlined.