Is lumbar drainage of postoperative cerebrospinal fluid fistula after spine surgery effective?

AIM: This study is a retrospective consecutive case series analysis of 198 patients who underwent spine surgery between 2009 and 2010. The aim of this paper was to assess the efficacy and safeness of bed rest and lumbar drainage in treating postoperative CSF fistula. Postoperative cerebrospinal fluid (CSF) fistula is a well-known complication in spine surgery which lead to a significant change in length of hospitalization and possible postoperative complications. Management of CSF leaks has changed little over the past 20 years with no golden standard advocated from literature. METHODS: Postoperative CSF fistulas were described in 16 of 198 patients (8%) who underwent spine surgery between 2009 and 2010. The choice of the therapeutic strategy was based on the clinical condition of the patients, taking into account the possibility to maintain the prone position continuously and the risk of morbidity due to prolonged bed rest. Six patients were treated conservatively (position prone for three weeks), ten patients were treated by positioning an external CSF lumbar drainage for ten days. The mean follow-up period was ten months. RESULTS: All patients healed their wound properly and no adverse events were recorded. Patients treated conservatively were cured in a mean period of 30 days, while patients treated with CSF drainage were cured in a mean period of 10 days. CONCLUSION: Lumbar drainage seems to be effective and safe both in preventing CSF fistula in cases of large dural tears and debilitated/irradiated patients and in treating CSF leaks.

Giant calcified thoracic herniated disc: considerations aiming a proper surgical strategy.

AIM: Giant herniated thoracic disc (HTD) is a rare disease that, unlike other thoracic disc herniations of different size, need a different surgical management. The copresence of ''giant'' volume and calcification of the herniated disc heavily affects the surgical difficulty and is not elsewhere described. METHODS: Seven cases of surgically treated giant calcified HTDs were considered in this study. Five of them were females and two males, age range 18-63 years. Before and after surgery, all patients underwent computed tomography myelography, magnetic resonance imaging or both pre-and postoperatively. Functional outcomes were assessed using the Asia grading system preoperatively, immediately after surgery, and at long-term follow-up examination. The mean overall follow-up period was 36 months. All patients presented with various grades of myelopathy: according to the Asia impairment scale, two were grade B, four were grade C and one were grade D. Six patients underwent an anterior approach, i.e. thoracotomy, and one patients underwent a posterolateral approach, i.e. peduncolocostotrasversectomy. RESULTS: Based on an analysis of the long-term follow-up data, the Asia grade improved in five patients (71.4%), stabilized (no grade change) in one (14.3%), and worsened in one (14.3%). CONCLUSIONS: Giant calcified HTDs are particularly challenging surgical lesions and their volume and consistency are additional elements of difficulty. This article presents authors' personal experience on a small but extraordinary series of giant and calcified thoracic herniated discs and the problems encountered in the management of this peculiar pathology since an accurate surgical planning leads to better clinical results.

Aggressive recurrence of intra-extradural cervico-thoracic meningothelial meningioma.

The authors analysed the case of a 53-years-old woman who presented with an C5-D1 intra-extradural mass. Following subtotal removal, the tumour was histologically classified as meningothelial meningioma and no radiotherapy was recommended. The neuroradiological workup demonstrated that the lesion was stable one year after the operation but, a few months later a tumour recurrence with huge bone destruction was detected. The tumour was totally resected and a circumferential stabilization was performed. Histology remained unchanged but radiotherapy was now recommended. One year after a new recurrence was detected and the patient died. The authors discuss the extremely malignant behaviour of a tumour classified as benign.