Cerebrospinal fluid leak during cervical corpectomy for ossified posterior longitudinal ligament: incidence, management, and outcome.

STUDY DESIGN: Retrospective. OBJECTIVE: To study the incidence of intraoperative cerebrospinal fluid (CSF) leak in patients with ossified posterior longitudinal ligament (OPLL) undergoing central cervical corpectomy (CC) and to describe a reliable technique for treating the leak after CC. SUMMARY OF BACKGROUND DATA: The rate of dural tear after CC is higher in patients with OPLL compared to other causes of cervical spinal stenosis. Various techniques have been described to deal with dural tears with CSF leak in OPLL. We assessed the efficacy of the repair technique used to deal with this complication in our patients with OPLL who had undergone CC. METHODS: A retrospective study was performed of all patients diagnosed with OPLL (n = 144) who had undergone CC between July 1992 and June 2007 (15 years). The dural defect was repaired with an onlay graft of crushed muscle/fascia and a layer of gelatin sponge. Bed rest and a lumbar subarachnoid drain were used for 5 days after surgery. RESULTS: Intraoperative CSF leak was noted in 9 patients (6.3%). The dural defects ranged in size from a few mm to about 15 mm (10-75 mm). All patients had a successful repair with no patient requiring reoperation for the CSF leak. CONCLUSION: Intraoperative CSF leak was encountered in 6.3% of patients undergoing CC for OPLL. A successful repair was achieved using fascial graft, gelatin sponge, lumbar CSF drainage, and bed rest.

Acute graft extrusion following central corpectomy in patients with cervical spondylotic myelopathy and ossified posterior longitudinal ligament.

We studied the influence of surgeon experience, number of levels operated and level of the lower mortise on acute graft extrusion in patients undergoing uninstrumented one-level to three-level central corpectomy (CC) for cervical spondylotic myelopathy (CSM) or ossified posterior longitudinal ligament (OPLL). Between 1992 and 2005, 410 consecutive patients underwent one-level to three-level CC with autologous iliac (in one-level and two-level corpectomy) or fibular (in three-level corpectomy) graft. The surgeon's experience was divided into four eras (I-IV; three eras of 100 consecutive patients each and the fourth with the last 110 patients). Eight patients (1.95%) experienced acute graft migration and seven required re-exploration. The graft extrusion rate in the first era was significantly higher than in the other three eras (6%, 1%, 1%, 0%; p=0.01) implying a significant learning curve. The extrusion rates for one-level, two-level and three-level CC were not significantly different (3%, 1.6%, 0% respectively; p=0.3). The extrusion rate for grafts ending in the C7 body (3/230, 1.6%) was not significantly different from the data for grafts ending in other bodies (5/180, 2.8%) (p=0.23). There is a low incidence of acute graft migration in patients undergoing uninstrumented CC with autologous bone grafts with a significant learning curve in avoiding graft extrusion.

Cranial melioidosis presenting as a mass lesion or osteomyelitis.

OBJECT: Melioidosis is caused by Burkholderia pseudomallei and causes multiple abscesses in different organs of the body. Cranial melioidosis, although uncommon, is sometimes confused with tuberculosis and is therefore under-recognized. The authors report on 6 cases of cranial infections caused by Burkholderia pseudomallei, presenting as mass lesions or cranial osteomyelitis, and review the literature. METHODS: The authors performed a retrospective review of the records of patients with cranial melioidosis treated at their institution between 1998 and 2005 to determine the presentation, management, and outcome of patients with this infection. RESULTS: Of the 6 patients diagnosed with cranial melioidosis during this period, 4 had brain abscesses and 2 had cranial osteomyelitis. All patients were treated surgically, and a diagnosis was made on the basis of histopathological studies. All patients were started on antibiotic therapy following surgery and this was continued for 6 months. One patient died soon after stereotactic aspiration of a brain abscess, and the other 5 patients had good outcomes. CONCLUSIONS: Cranial melioidosis is probably more prevalent than has been previously reported. A high index of suspicion, early diagnosis, initiation of appropriate antibiotic therapy and treatment for an adequate period are essential for assuring good outcome in patients with cranial melioidosis. The authors recommend surgery followed by intravenous ceftazidime treatment for 6 weeks and oral cotrimoxazole for 6 months thereafter in patients with cranial melioidosis.

Trigonal cavernous angiomas: report of three cases and review of literature.

BACKGROUND: Intraventricular cavernous angiomas are very rare. Only few cases of trigonal angiomas have been reported. CASE DESCRIPTION: We report three cases of trigonal cavernous angiomas who presented with raised intracranial pressure or seizures and who underwent total excision with a good recovery. We also review the literature and discuss surgical approaches. CONCLUSION: On magnetic resonance imaging, intraventricular cavernous angiomas lack the hemosiderin ring characteristically seen around parenchymal cavernous angiomas. This explains why trigonal cavernous angiomas can mimic malignant neoplasm on imaging, and they should be considered in the differential diagnosis of intraventricular masses. Total excision should be the goal of surgery.

Intraoperative mapping of sacral nervous system (S2-4).

Electrophysiological mapping of the sacral nervous system was used during operations on 80 patients with conus and cauda equina lesions. At surgery, under controlled muscle relaxation, the sacral neural elements (S2-4) were mapped using direct mono-polar stimulation and recording of compound muscle action potentials (CMAPs) from the external anal sphincter (EAS). Responses were obtained in 86.25% (69/80) of the patients. In 33 (82.5%) out of 40 patients with preoperative deficits involving the S2-4 segments, CMAPs could be elicited. Identification of nerve roots was useful in dissection of lipomyelomeningocoeles, tumour excisions and untethering of filum terminale. In three patients, stimulation of the filum terminale elicited motor responses and, hence, it was not sectioned. Intraoperative mapping of the S2-4 nerve roots under controlled muscle relaxation is feasible in a majority of patients, including those with deficits involving S2-4. This method was useful in sparing viable nerve roots during surgery in conus and cauda equina regions, and identification of 'functional' filum terminale.

Lumbo-costo-vertebral syndrome with posterior spinal dysraphism.

Lumbo-costo-vertebral syndrome, which includes abnormalities of the vertebral bodies, ribs and trunk musculature, is very rare and only few cases have been reported. We report a case of 18-month-old female child with absent ribs, hemivertebrae, superior lumbar hernia (features of lumbo-costo-vertebral syndrome) and posterior spinal dysraphism, which to our knowledge is the first case in the English literature with such a combination of defects. Embryology and management of the case is discussed.

Unusual presentation of the "syndrome of the trephined".

A 45-year-old lady underwent right fronto-parietal craniotomy and subtotal excision of a parasagittal meningioma. Bone flap was not replaced as it was infiltrated by the tumor. In the postoperative period she developed episodes of altered sensorium associated with worsening of left hemiparesis and a sunken scalp at the site of bone defect. Computed tomography (CT) of brain showed sunken scalp flap in the right fronto-parietal region with compression of the underlying brain. A diagnosis of syndrome of the trephined was considered and her symptoms improved with cranioplasty. Pathophysiology of the syndrome of the trephined is discussed.