Pain measurement from the neurosurgical standpoint.

A selective review of the current methods of pain measurement and validation (psychophysical methods, verbal and analogical scales, psychological tests) is presented with emphasis on patient selection for surgical pain relief, and analysis of outcome. The identification of homogeneous groups of patients with clinical and research objectives is prevented by the lack of a reliable pain scale, based on the assessment of objective and comprehensive parameters. This obstacle seems to be inherent to the complex nature of human pain experience. Psychiatric examination has proved important to elucidate the operative indications, particularly in cases of non-malignant obscure neuralgias. The importance of separate validation of the pain compliant and the psychiatric assessment is stressed. A critical comment is made on Hitchcock's pain scale and Lindqvist's psychiatric classification of candidates for surgery.

Pain measurement from the neurosurgical standpoint

A selective review of the current methods of pain measurement and validation (psychophysical methods, verbal and analogical scales, psychological tests) is presented with emphasis on patient selection for surgical pain relief, and analysis of outcome. The identification of hemogeneous groups of patients with clinical and research objectives is prevented by the lack of a reliable pain scale, based on the assessment of objective and comprehensive parameters. This obstacle seems to be inherent to the complex nature of human pain experience. Psychiatric examination has proved important to alucidate to operative indications, particularly in cases of non-malignant obscure neuralgias. The importance of separate validation of the pain compliant and the psychiatric assessment is stressed. A critical comment is made on Hitchcock's pain scale and Lindqvist's psychiatric classification of candidates for surgery

[Measurement of the dura mater displacement in median suboccipital puncture]. / Mensuração do deslocamento da dura-máter na punção suboccipital mediana.

Report of a study of the dynamic anatomy of the median suboccipital puncture of the cisterna magna cerebello medullaris, carried out on fresh cadavers. Direct inspection of the internal surface of the dura mater (DM) at the craniocervical region was possible by removing the calvarium and brain (sectioned at the upper cervical cord), during routine necropsies. Dislocation of the DM over the needle tip preceding dural penetration (so-called "dural tenting") was observed in all punctures (n = 30), measuring 3.12 (2.0-4.2) mm.

Adult peripheral neuroblastoma.

Report of clinical features, diagnostic and surgical aspects observed in a case of adult peripheral neuroblastoma infiltrative of the lumbosacral plexuses. The patient, a 39-year-old male, presented with sciatalgia and progressive crural monoplegia. Characteristic histological features of this rare tumor are described. Surgical resection was attempted via a posterior transgluteal approach to the retroperitoneum through the greater sciatic foramen.

Adult peripheral neuroblastoma

Relato de caso de neuroblastoma periférico em paciente adulto, com 39 anos de idade, do sexo masculino. O tumor de localizaçäo retroperitoneal, acometeu o plexo lombossacral esquerdo. Os primeiros sintomas foram de lombociatalgia, progredindo com monoparesia crural pronunciada e dor incapacitante. Säo descritas as características histológicas dessa neoplasia rara na idade adulta, incluindo estudo imuno-histoquímico e microscopia eletrônica, bem como a técnica cirúrgica empregada para sua ressecçäo (via posterior) transglutea, sendo a cavidade pélvica alcancada atravéz do forame isquiático maior). Os neuroblastomas devem ser considerados no diagnóstico diferencial do chamdo grupo histológico dos tumores malignos de células pequenas, mesmo em se tratando de pacientes adultos

[Vagoglossopharyngeal neuralgia]. / Nevralgia vagoglossofaringea.

Review of current opinions concerning clinical presentation, etiology, differential diagnosis and management of vagoglossopharyngeal neuralgia. Three cases are reported, treated by intracranial section of n. IX (alone in one case) and upper rootlets of n. X. In two patients no vascular compression of the nerves was observed. In one case an atheromatous elongated basilar artery was observed compressing and deforming the medulla oblongata at the entry zone of nerves IX-X. In this case, pain paroxysms recurred some weeks after surgery, and the patient underwent re-operation (microvascular decompression of the medulla) with good outcome. Clinical implications of the complex sensitive innervation of profound regions of the face and cervicofacial region are emphasized. Certain circumstances, such as gustatory pain due to sympathetic denervation of parotid gland, the neck-tongue syndrome and oropharyngeal pain by irritation of the first cervical spinal nerve (during lateral suboccipital puncture), point to the fact that in this region similar symptoms may be provoked by mechanisms involving different peripheric pain pathways. The theory of microvascular compression in the pathogeny of cranial nerve "hyperactive" dysfunctions is critically commented.

[Dura mater displacement in lateral cisternal punctures]. / Observações sobre o deslocamento da dura-máter nas punções cisternais laterais.

Report of an anatomic study of the lateral cisternal punctures (at the atlanto-occipital and C1-2 interspaces), carried out on fresh cadavers. Direct visualization of the internal surface of the dura mater (DM) at the cranio-cervical junctions was possible by removing the calvarium and brain (sectioned at the upper cervical spinal cord). Dislocation ("tenting") of the DM over the needle was observed in all occasions (n = 42), measuring 3.46 mm (2-6 mm).

[Lhermitte's sign during lateral cervical puncture: survey of possible accidents in the lateral C1-C2 puncture and report of 2 cases of spinal cord penetration]. / Sinal de Lhermitte durante punção cervical lateral: sumário dos acidentes possíveis na punção lateral C1-C2 e relato de dois casos de penetração medular.

Lhermitte's sign was referred by two patients during lateral cervical puncture (LCP) due to accidental puncture of the spinal cord; no sequelae were observed in these patients. A brief review of the literature is presented, concerning: 1. Lhermitte's sign; 2. reported accidents during LCP. Avoidance of neural and/or vascular injuries is possible by employing the posterior approach to LCP (puncture of the dorsal spinal subarachnoid space at C1-C2). The lateral suboccipital puncture (at the atlanto-occipital space) of the cisterna magna is also recommended.

[Pure spinal leptomeningeal cysticercosis]. / Cisticercose espinhal leptomeníngea pura.

An adult female patient presented with an exclusively spinal leptomeningeal infestation by cysticercosis (restricted to the cauda equina), verified in surgery. The rôle of the vertebral vein system in the spread of cysticercosis larvae is discussed. A commentary on the possibility that cysticercosis of the basal cisterns may be due to ascending migration of primarily spinal cysticerel, as originally proposed by Isamat de la Riva, is stated.

[Lumbosacral neoplastic radiculopathy]. / Radiculopatia neoplásica lombossacral.

Lumbar-disc protrusions (LDP) constitute well-defined syndromes on clinical and anatomical grounds, and neurosurgeons are prone to rely upon the clinical signs to identify the level of disc protrusion when a "typical" case is found. Sometimes, non-contrasted computerized tomographic (CT) scans centered on the L5-S1, L4-L5 and L3-L4 interspaces and spine roentgenograms are the only special ancillary means in presurgical evaluation. We report three patients from our series, in which neoplastic spinal disease presented as classic LDP (one patient with a cauda equina schwannoma, and two with metastatic carcinoma). The cases were chosen because they posed special problems to the referred radiodiagnostic routine. Systematic CT-evaluation of the sacrum and conus medullaris zone is recommended in every patient with lumbosacral radiculopathy, and intrathecal contrast should be employed in patients with unreliable findings or normal CT-scans.

An arachnoid cyst extending above and below the foramen magnum.

A case of progressive bulbar and long tract symptoms with hydrocephalus of eleven years duration in a 23-year-old man, in whom an arachnoid cyst of the cisterna magna cerebellomedullaris was disclosed at operation.

[Pharyngeal pain during lateral suboccipital puncture]. / Dor faríngea durante punção suboccipital lateral.

Oropharyngeal pain was referred by five fully conscious and collaborative patients during lateral suboccipital puncture (LSP) of the cisterna magna, performed for myelography and/or cerebrospinal fluid collection. The anastomotic connections between the lower cranial nerves, the sympathetic nerves and the upper cervical spinal nerves are reviewed, with emphasis on the relationship between the first cervical nerve (C1), the superior cervical ganglion of the sympathetic trunk, and the spinal accessory nerve (nerve XI), and their central connections. The authors conclude that pharyngeal pain during LSP is provoked by the stimulation of afferent visceral fibers of C1, or of the gray communicating branches of the superior cervical ganglion to C1.

So-called tethered cervical spinal cord.

A case is reported of the so-called Tethered Cervical Spinal Cord Syndrome presenting as multiradicular pain on an upper limb in a 45-year old woman, in whom spina bifida occulta (C6) was associated with an intramedullary lipoma, intradural fibrous adhesions and the fusion of the sixth and seventh cervical vertebrae. Surgical release of the tether was ineffective, and the patient underwent a posterior rhizotomy for pain relief. The clinical and maldevelopmental aspects of this most uncommon form of spinal cord tethering are discussed briefly.

[Brief comments on the pathogenesis of spinal cysticercosis]. / Breve comentário sobre a patogenia da cisticercose espinhal.

The spinal forms of neurocysticercosis are rather rare. The more common presentation is the leptomeningeal form. We have reported two patients with an exclusively spinal involvement verified through surgery. The current theory of downward migration of the parasites from the cerebral to the spinal subarachnoid space cannot explain primary spinal forms, and it is suggested that retrograde flow through the epidural vertebral veins provides an alternative route.

Malignization of an arachnoid cyst.

A case of evolvement of fibrosarcoma from a supratentorial arachnoid cyst (verified in surgery five years before) is presented, with brief comments on the embryonic origin of the tissues involved.

Malignization of an arachnoid cyst

Cistos aracnóideos representam displasia mesodérmica focal (do neurotélio subdural), sendo sua apresentaçäo clínica decorrente de seu tamanho e localizaçäo. No presente caso, um fibrossarcoma originou-se de cisto aracnóideo supratentorial verificado em cirurgia cinco anos antes. A malignizaçäo de cistos aracnóideos deve ser muito rara, e esse é provavelmente o primeiro caso relatado na literatura

Breve comentário sobre a patogenia da cisticercose espinhal / Brief comments on the pathogenesis of spinal cysticercosis

A hipótese de que embriöes cisticereóticos possam alcançar os espaços subaracnóideos espinhais por migraçäo descendente a partir de espaços intraxcranianos previamente infestados näo é compatível ao acometimento leptomeningeo espinhal primário, que observamos em duas pacientes. É sugerido que nesses casos os embriöes invadem o sistema nervoso central através do fluxo sangüíneo retrógrado pelo plexo venoso vertebral interno e veias intervertebrais, e que o compartimento intracraniano do líqüido cefalorraqueano possa ser secundariamente invadido pelos cisticercos

[Lateral cervical puncture for myelography and cerebrospinal fluid collection: technical note]. / Punção cervical lateral para mielografia e coleta do líquido cefalorraqueano: nota técnica.

The lateral cervical puncture for myelography or cerebrospinal fluid collection is a modification of the technique of percutaneous cervical cordotomy. It may be performed at the atlanto-axial or atlanto-occipital interspace. It is simple to perform, and appears to be safer and more easily mastered than suboccipital puncture, with no more discomfort to the patient than that associated with lumbar puncture.

[Multiple cerebral abscesses: apropos of 2 cases]. / Abscessos cerebrais múltiplos: a propósito de dois casos.

The authors summarize the current concepts regarding pathogenesis and surgical management of multiple brain abscesses, and report their experience with two recent cases with computerized tomographic follow-up.