Omentomyelopexy for the Treatment of a Persistent Lumbar Pseudomeningocele: A Case Report With Technical Note.

BACKGROUND AND IMPORTANCE: Pseudomeningoceles are extradural accumulations of cerebrospinal fluid. In most cases, they appear as a complication of spinal operations. Omentomyelopexy is a surgery in which an autologous omentum flap is implanted over the dural opening. We describe a case of persistent pseudomeningocele treated with omentomyelopexy. CLINICAL PRESENTATION: A 37-year-old man sustained a T12-L1 AO B3 fracture during a motorcycle accident. He underwent posterolateral fusion and then neurological rehabilitation. Two years later, however, his condition worsened, and he experienced progressive weakness-he was diagnosed with an intramedullary cyst, which was treated with laminectomy, arachnolysis and cystotomy. A pseudomeningocele developed afterward, and the patient underwent multiple reoperations in the following years, none of which were effective. Omentomyelopexy, a complex procedure aimed to facilitate cerebrospinal fluid absorption and subsequent formation of a permanent membrane, was offered to the patient as a "last resort." After undergoing omentomyelopexy, his pseudomeningocele resolved. CONCLUSION: Although it should be reserved for exceptionally pertinent cases, omentomyelopexy is a viable option for managing persistent pseudomeningocele. However, further research is needed to better understand the effects and benefits of omentomyelopexy in this context.

Cranial Reconstruction Using Autologous Bone and Methylmethacrilate.

BACKGROUND: Having in mind the importance of reconstruction of the calvaria, our goal was to compare the complication rates following the use of autologous bone and methylmethacrilate grafts, and explain the factors influencing them. METHODS: The authors collected information of all the patients undergoing cranial reconstructive surgery (N = 149) at the Military Medical Academy in Belgrade. Procedures were performed either using a craniotomy bone flap, removed and replaced in the same act, or using methylmethacrilate. These 2 groups were compared using the Chi-squared test, controlling for the confounding influence of the size of the defect. RESULTS: Intracranial neoplasms were the cause for the reconstruction in 71.1% of patients. The total complication rate was 7.4%, while the infection rate was 5.4%. The infection rate was significantly higher in those procedures done using methylmethacrilate (11.3% compared with 2.1%, P = 0.017), but when controlling for the confounding effect of the size of the defect treated, the difference in infection rate was significant only in large defects (13.9% compared with 2%, P = 0.031), while for small defects the difference was not statistically significant. CONCLUSIONS: Our study suggests that the material used for reconstruction of calvaria influences the infection rate only in large and complicated defects. Considering the importance of the reconstruction, further studies should explore and confirm the role of material type on the rate of complications.

Symptomatic migration of a Kirschner wire into the spinal canal without spinal cord injury: case report.

The migration of Kirschner wires (K-wires) is a rare but significant complication of osteosynthesis interventions, and numerous cases of wire migrations have been reported in the literature. Nevertheless, migration into the spinal canal is very rare, with only 10 cases reported thus far. The authors present a case of K-wire migration into the spinal canal, together with a review of the relevant literature. A 30-year-old male who had suffered a right clavicle fracture in a motorcycle accident was treated with 2 K-wires. Four months after the initial fixation, while he was lifting his child, he experienced short-term pain in his back, numbness in all 4 extremities, followed by a spontaneous decrease in numbness affecting only the ulnar nerve dermatomes bilaterally, and a persistent headache. No urinary incontinence was present. Simple radiography studies of the cervical spine revealed a wire in the spinal canal, penetrating the T-2 foramen and reaching the contralateral foramen of the same vertebra. Computerized tomography showed the wire positioned in front of the spinal cord. Surgery for wire extraction was performed with the patient under general anesthesia, and he experienced relief of the symptoms immediately after surgery. This case is unique because the wire caused no damage to the spinal cord but did cause compression-related symptomatology and headache, which have not been reported in osteosynthesis wire migration to the thoracic region.

Combined Treatment of Ruptured Middle Cerebral Artery Aneurysm Followed by Subarachnoid Hemorrhage and Acute Subdural Hematoma in Multiple Aneurysm Disease of Cerebral Blood Vessels: Case Report

Aneurysms of blood vessels at the base of the brain are pathological focal out-pouchings, usually found at the branching points of the arteries. Aneurysm can remain silent for life. Clinical presentation is due to rupture and bleeding. In only 1.3% of cases it results in subdural hematoma, which is associated with direct interaction of the aneurysm with the basal arachnoid membrane. Multiple aneurysms are present in 15% to 33% of cases with subarachnoid hemorrhage. Assessment of these patients is more complicated, as there are no specific signs to pinpoint/detect the aneurysm that has ruptured. This report presents a 44-year-old female patient suffering from multiple cerebral aneurysm disease, who was urgently treated after rupture by both endovascular (for multiple aneurysms) and surgical (for acute subdural hematoma) approach in the same act under general anesthesia, which resulted in complete recovery of the patient.

Cranial reconstruction with prefabricated 3D implant after a gunshot injury: A case report.

Introduction: Complex defects of skull bones with different etiology, still present the challenge in reconstructive surgery. The goldstandard for cranioplasty is the autologous calvarial bone graft removed during surgery which cannot be always applied, especially in gunshot wounds for sometimes complete bone destruction. Autologous reconstruction with split calvarial, rib bones or iliac bone graft is also possible. Materials routinely used for reconstructions like titanium mesh, polymethyl metacrylate (PMMA), and other have numerous disadvantages and limitations. Case report: We presented a patient with gunshot injury to the head with residual large bone defect in the frontal region, with involvement of the skull base, and open frontal sinus. After conservative treatment, six months after the injury, reconstruction of the residual bone defect was performed. The chosen material was computerdesigned PEEK-OPTIMA® implant, manufactured on the basis of MSCT scan. This material has not been used in this region so far. The postoperative and follow-up period of the next 12 months passed without surgical complications, neurological deficit, with satisfactory functional and aesthetic results. Conclusion: Implanted bone replacement was designed and manufactured precisely according to the skull defect, and we found it suitable for the treatment of complex defects of the cranium. Early results are in favor of this cranioplasty method over standardized materials. Therefore, this material is expected to become a method of choice for reconstructive surgery of bony defects of the face and skull especially in complex cases.

[Functional magnetic resonance imaging of cortical changes in a low-grade glioma patient].

INTRODUCTION: New methods for studying brain functions have provided the new insights into human brain. It is really possible to study a cortical adaptation in adults who have sustained injury. We reported cortical changes in a left frontal low-grade glioma patient during disease progression and after reoperation by functional magnetic resonance imaging (fMRI). CASE REPORT: The use of fMRI exams for localisation of eloquent motor and language areas were performed three times in a period of 15 months: seven years after initial tumor resection, eleven months later and three months after the reoperation. The first fMRI demonstrated cortical activation for motor tasks in the expected location of primary motor area while later examinations showed activations of both primary motor areas for right hand movement. The first exam language evaluation showed the left hemisphere dominance for both language tasks, while the second fMRI demonstrated the right hemisphere dominance for complex word generation task, but the left hemisphere remained dominant in simple language task. After the reoperation, language mapping revealed the left hemisphere dominance for both language tasks. CONCLUSION: fMRI evaluation of cortical changes in low-grade glioma patients may additionally optimize and individualize neurosurgical treatment.

[Treatment of degenerative chronic low back pain with fluoroscopically guided epidural procaine-corticosteroid injection].

BACKGROUND/AIM: Low back pain is one of the most common painful conditions in the modern age. Therefore, it is very important to establish the most effective protocol for the treatment of this condition. The aim of this study was to find out if fluoroscopically, guided epidural procaine-corticosteroid injection is effective in the treatment of degenerative chronic low back pain. METHODS: This prospective cohort study was performed in the Military Medical Academy from September 2005 to June 2006 and included 60 patients of both sexes, 34-85 years of age. Degenerative changes of lumbosacral spine were determined by magnetic resonance imaging. The intensity of low back pain was evaluated by subjective (Roland's scale) and objective parameter (Lazarevic sign). Epidural procaine-corticosteroid injection was applied in the patients with low back pain not responding to conservative therapy. After the application of injection, effects of the therapy were followed up. RESULTS: In 92% of the patients there was a reduction of pain intensity for three months, in 4.8% a reduction for a month, but after another injection they felt pain reduction for the next three months. One patient (2.3%) had pain reduction for one month. CONCLUSION: In the treatment of degenerative chronic low back pain, not responding to conservative therapy with nonsteroidal anti-inflammatory drugs, epidural procaine-corticosteroid injection have a satisfactory short-term as well as a long-term analgesic effect.

[Endovascular treatment of carotid-cavernous fistula type A with platinium coils].

BACKGROUND: Carotid-cavernous fistulas are abnormal communications between carotid arteries or their branches and the cavernous system caused mostly by trauma. Posttraumatic fistulas represent 70% of all carotid-cavernous fistulas and they are mostly high-flow shunts (type A). This type gives characteristic eye symptoms. CASE REPORT: This paper presents a 44-year old male patient with carotid-cavernous fistula as a result of penetrating head injury. In clinical presentation the patient had exophthalmos, conjunctival chemosis and weakening of vision on the right eye, headache and diplopia. Digital subtracted angiography showed high-flow carotid-cavernous fistula, which was vascularised from the left carotid artery and from vertebrobasilar artery. Endovascular embolization with platinum coils was performed through the transarterial route (endoarterial approach). Check angiogram confirmed that the fistula was closed and that no new communications developed. CONCLUSION: Embolization of complex carotid-cavernous fistula type A was successfully performed with platinum coils by endovascular approach.