Translaminar screw fixation of a kyphosis of the cervical and thoracic spine in neurofibromatosis.

The spinal manifestations of neurofibromatosis include cervicothoracic kyphosis, in which scalloping of the vertebral body and erosion of the pedicles may render conventional techniques of fixation impossible. We describe a case of cervicothoracic kyphosis managed operatively with a vascularised fibular graft anteriorly across the apex of the kyphus, followed by a long posterior construct using translaminar screws, which allow segmental fixation in vertebral bodies where placement of the pedicle screws was impracticable.

Traumatic occipitocervical disruption: a new technique for stabilisation. Case report and literature review.

Traumatic atlanto-occipital dislocation in adults is usually fatal and survival without neurological deficit is rare. The surgical management of those who do survive is difficult and controversial. Most authorities recommend posterior occipitoaxial fusion, but this compromises cervical rotation. We describe a case in which a patient with a traumatic atlanto-occipital disruption but no neurological deficit was treated by atlanto-occipital fusion using a new technique consisting of cancellous bone autografting supported by an occipital plate linked by rods to lateral mass screws in the atlas. The technique is described in detail. At one year the neck was stable, radiological fusion had been achieved, and atlantoaxial rotation preserved. The rationale behind this approach is discussed and the relevant literature reviewed. We recommend the technique for injuries of this type.

Gorham's disease of skull base and cervical spine--confusing picture in a two year old.

The unusual presentation of Gorham's disease of skull base and cervical spine in a two-year-old female child with radiological signs mimicking those of raised intracranial pressure is discussed. The differential diagnosis consists of skull base tumours, meningitis, osteomyelitis of the base of skull, congenital hydrocephalaus and congenital syndromes involving the skull base. Pathologically it can be very difficult to differentiate it from lymphangioma of the bone. Difficulty in establishing the diagnosis is discussed along with failure of radiotherapy and palmidronate therapy to cause arrest of the disease process and failure of surgery to provide stabilisation. We describe the course of the disease in this child over the period of last eight years. To the best of our knowledge this is the youngest case of Gorham's described so far.

Reconstruction of skull base and dura using rectus abdominis muscle combined with a vascularised fascial perforator flap.

The goal of reconstruction of the skull base is to repair dural defects with a watertight seal and separate it from the nasopharynx and the exterior environment with well vascularised tissue. This prevents cerebro-spinal fluid leakage and secondary contamination leading to the potentially life threatening complications of meningitis or extradural abscess. Following large composite resections, traditional techniques to repair the dura involve the use of an autologous fascial graft or a pericranial flap, whilst a regional pedicled or free muscle flap is used to close the dead space defect. We describe a technique performed in two cases, whereby a single flap, the rectus abdominis muscle free flap, can be used to provide vascularised reconstruction both of the dura and the skull base. The anterior rectus sheath, islanded on a single perforator vessel, is used as a vascularised layer to reconstruct dura, whilst the supporting rectus abdominis muscle provides bulk to obliterate dead space. We show that this flap is suitable for reconstruction even in the presence of chronic infection. Advantages of a vascularised reconstruction are the rapid healing of the wound, even after radiotherapy, the delivery of systemic antibiotics to the site of the operation, and that it may allow early postoperative radiotherapy to be planned.

'Look beneath the stockings'--delayed diagnosis of ankle fractures in patients with thoracic cord compression.

Two patients with thoracic cord compression and ankle fractures are presented. The diagnosis and treatment of the ankle fractures was delayed in these patients. The lack of pain sensation in the lower limbs and the use of TED stockings that covered the area of abnormality were the reasons for the delayed diagnosis.

Petrosectomies for invasive tumours: surgery and reconstruction.

Tumours involving the temporal bone have historically carried a bad prognosis. The only prospect of cure is radical en bloc resection. Temporal bone resection for malignancies is, however, such a formidable undertaking that many centres label such tumours as unresectable. Additionally, the enormity of the surgical defect poses a major reconstructive challenge. A review of 14 petrosectomies (in 12 males and 2 females) performed for extensively invasive neoplasms in and around the ear is presented. All underwent immediate reconstruction, the majority (12/14) with free tissue transfers. 9 of the 14 patients (64%) are still alive after a mean follow-up of 70 months (range 4-8 years). With the use of free tissue transfers, an aggressive approach with regard to the resection margins can safely be adopted in the full knowledge that the eventual size of the defect need not compromise tumour clearance. Additionally, free flaps provided a reliable dural seal. This approach of radical en bloc resection with free flap reconstruction has decreased the mortality (compared to the literature), while largely reducing the morbidity to that of unavoidable cranial nerve resection.

Tuberculoma of the cavernous sinus--a case report.

Although tuberculosis among Asian immigrants in Britain is not uncommon, intracranial tuberculomas are rare. An unusual case of a tuberculoma located in the left cavernous sinus is reported.

The 3-M syndrome: risk of intracerebral aneurysm?

We describe a child with typical features of the 3-M syndrome who presented with acute hydrocephalus owing to haemorrhage from one of two intracranial cerebral vascular aneurysms. We suggest that other children with this disorder should be screened for similar complications.

Differences between neurological and neurosurgical approaches in the management of malignant brain tumours.

The management and outcome in 205 patients diagnosed as having cerebral gliomas over five years were reviewed. Patients referred to neurologists and neurosurgeons had similar clinical features and similar results on computed tomography. Patients referred to neurologists underwent burr hole biopsy less often and had better short term morbidity than patients referred to neurosurgeons, although final outcome was the same in both groups. Few patients underwent other surgical procedures. Referral for radiotherapy was usually by neurosurgeons, although this did not significantly affect long term survival. The implications for the management of patients with primary malignant brain tumours and the need for prospective studies are discussed.

An abdominal extraperitoneal approach for the incarcerated inguinal hernia of infancy.

Incarcerated inguinal hernias in infancy often present considerable technical problems when approached through the inguinal canal. The advantages and technique of an abdominal extraperitoneal approach are described, and results show this approach to be safer for the patient and easier for the surgeon.