Nontraumatic spinal epidural hematoma during pregnancy: diagnosis and management concerns.

OBJECTIVE: Nontraumatic spinal epidural hematoma (SEH) during pregnancy is rare. Therefore, appropriate management of this occurrence is not well defined. The aim of this study was to extensively review the literature on this subject, to propose some novel treatment guidelines. METHODS: Electronic databases, manual reviews and conference proceedings up to December 2011 were systematically reviewed. Articles were deemed eligible for inclusion in this study if they dealt with nontraumatic SEH during pregnancy. Search protocols and data were independently assessed by two authors. RESULTS: In all, 23 case reports were found to be appropriate for review. The mean patient age was 28 years and gestational age was 33.2 weeks. Thirteen cases presented with acute interscapular pain. The clinical picture consisted of paraplegia, which occurred approximately 63 h after pain onset. Spinal cord decompression was performed within an average time of 20 h after neurological deficit onset. Fifteen patients had cesarean deliveries, even when the gestational age was less than 36 weeks. CONCLUSION: This review failed to identify articles, other than case reports, which could assist in the formation of new guidelines to treat SEH in pregnancy. However, we believe that SEH may be managed neurosurgically, without requiring prior, premature, cesarean section.

Anterior screw fixation of type IIB odontoid fractures in octogenarians.

PURPOSE: Type IIB odontoid fractures (OF) in elderly patients are life-threatening conditions. Optimal treatment of these fractures is still controversial. The aim of this study was to assess the clinical and radiological outcome of surgically treated type IIB OF by anterior screw fixation in octogenarians. METHODS: Eleven octogenarians with type IIB OF were operated using anterior screw fixation. Follow-up assessment included operative mortality and morbidity rates, long-term functional outcome and fracture union and stability. RESULTS: There was neither operative mortality nor morbidity. Five patients had excellent clinical outcome, two good outcome, one fair and three poor. Two patients died of unrelated causes 2 months after surgery. Radiographs showed stable bone union in four patients and stable fibrous union in five patients. CONCLUSIONS: Given the results in this short series, we suggest that anterior screw fixation of Type IIB OF may be offered as primary treatment in octogenarians.

Brown-Sequard syndrome revealing intradural thoracic disc herniation.

Brown-Sequard syndrome (BSS) is a rare form of severe myelopathy characterised by a clinical picture reflecting hemisection of the spinal cord. This syndrome is mostly due to a penetrating injury to the spine but many other non-traumatic causes have been described. Intradural thoracic disc herniation (TDH) is one of the rare aetiologies of this syndrome. Despite progress in imaging techniques, diagnosis and treatment remain difficult. We retrospectively reviewed one of the largest reported series of six patients with BSS revealing intradural TDH between 2003 and 2007. There was a marked female predominance and the mean age was 44 years. Before surgery, half of the patients had a severe neurological deficit. The mean duration of symptoms until surgery was 8.5 months (range 0.5-24 months). Spine magnetic resonance imaging (MRI) or spine computer tomography scan showed calcified TDH between T5-T6 and T9-T10. The intradural location of the thoracic herniation was strongly suspected from the clinical data. All the patients underwent posterolateral transpedicular surgery with an operative microscope to open the dura mater. The intradural location of the herniation was overlooked in one case and the patient underwent a second procedure. The dura mater was carefully closed. Two patients' condition worsened immediately after the surgery before slowly improving. All the other patients improved their neurological status immediately after the surgery and at 12 months follow-up. BSS with TDH on the spine MRI scan may be a warning symptom of the intradural location of the herniated disc. In such cases, spine surgeons are advised to use an operative magnification and to open the dura mater to avoid missing this potentially curable cause of severe myelopathy.

[Adams-Oliver syndrome: a case with minimal expression]. / Syndrome d'Adams-Oliver : à propos d'un cas d'expression minime.

Adams-Oliver syndrome is a rare congenital anomaly characterized by aplasia cutis congenita (ACC) and variable degrees of terminal transverse limb defects. We report on a neonatal case with the sporadic form of the disease with minimal expression, illustrating the wide spectrum of clinical expression in Adams-Oliver syndrome. We also review the literature and highlight the different pathogenetic hypotheses of this syndrome.

[A case of intramedullary primary melanocytic tumor: meningeal melanocytoma or malignant melanoma?]. / Un cas de tumeur mélanocytaire primitive intramédullaire: mélanocytome méningé ou mélanome malin?

We report a case of an intramedullary thoracic primary melanocytic tumor of the leptomeninges in a 38-year-old woman. According to the WHO classification, the lesion showed the histological features of a meningeal melanocytoma. Two local recurrences were successively operated on, two and three years after the first surgery respectively. The patient died of a subarachnoidian dissemination after a four year course. This case emphasized the therapeutic problems we have to deal with when facing an isolated black tumor of the central nervous system. The features and the differential diagnosis of the meningeal melanocytoma are detailed.

PCV chemotherapy for oligodendroglioma: response analyzed on T2 weighted-MRI.

OBJECTIVE: Because oligodendroglioma are infiltrative tumors, the Mac Donald's response criteria, usually used for solid and contrast-enhanced tumors, seem not to be adapted. To precise more relevant radiological criteria, the radiological response of oligodendroglioma to PCV chemotherapy was evaluated on T2 weighted-MRI sequences only. METHODS: 25 patients with oligodendroglioma grade A or B were retrospectively analyzed. They were treated with up to six cycles of PCV standard regimen. Tumor size was calculated before and at the end of the treatment, on T2 weighted-MRI, by two methods: volumetric reconstruction (method 1) and maximal cross-sectional area (method 2). Responses were defined according to new criteria on T2 weighted-MRI. RESULTS: According to these criteria and with the method 1, 7 of 25 patients (28%) had a partial response to the PCV, 14 patients (56%) had stabilized disease, and 4 patients (16%) had progressive disease. With the method 2, 6 had partial response (24%), 18 had stabilized disease (72%) and 1 had progressive disease. CONCLUSION: Response rate to PCV chemotherapy in this study was lower than response observed in the literature. Because of the infiltrative feature of oligodendroglioma, we think that the radiological response of these tumors should be evaluated on T2 weighted-MRI. The two methods of tumor size estimation used in this study were almost equivalent. Then, the maximal cross-sectional area measurement, more practical, could be retained.

Ventral transdural herniation of the thoracic spinal cord: surgical treatment in four cases and review of literature.

BACKGROUND: A specific cause of progressive Brown-Sequard syndrome has been identified: a ventral herniation of the thoracic spinal cord through the dural sleeve on one side. METHOD: Four female patients who were affected by a progressive Brown Sequard syndrome related to a transdural spinal cord herniation have been investigated and were submitted to surgery and postoperative evaluation. FINDINGS: The MRI scan showed atrophy and forward displacement of the spinal cord on one side and adhesion of the spinal cord to the dura mater. CT myelography demonstrated the disappearance of the premedullar rim at the level of the herniation and the shadow of the extradural herniation. Surgical treatment consisted in the excision of the arachnoid cyst when there was one, section of the dentate ligament, release of the adhesions, detachment of the spinal cord from the hernial orifice, and lastly suture of the dural tear or placement by a patch. Follow-up examination showed motor improvement with persistent sensory deficit in two cases and stabilisation in two cases. INTERPRETATION: The cause of the dural tear, either traumatic or congenital could not be confirmed in the four cases. Symptoms probably occur when herniation fills the orifice and strangulation happens which explains the late appearance and progressive evolution of this myelopathy. Mobilisation of the herniated spinal cord back into the intradural space can be achieved by surgery and may stop the evolution of the symptoms and signs.