Neurenteric cyst in an adult: a diagnosis in a quinquagenarian.

Neurenteric cysts are congenital lesions of the spine usually diagnosed in children. There are few reports of diagnosis in adults. The abnormality is thought to arise during embryonic life and can be associated with other congenital deformities. We describe a case where the diagnosis occurred in a 54-year-old woman, whose symptoms improved following surgical excision of the cyst. We postulate that the cyst contributed to symptoms of cord tethering rather than cord compression and that the lateness of presentation was due to age-related spinal degeneration.

Pilocytic astrocytoma of the adult--clinical features, radiological features and management.

Pilocytic astrocytoma is a histological subtype of astrocytoma classically located in the cerebellum of children and young adults. Cases occurring over the age of 30 years are rare and have not been classified in terms of their clinical features and management. Suitable cases were identified using diagnostic coding and by reviewing a neuropathology database. Casenotes and neuroradiology were reviewed retrospectively. Ten cases were identified over a 6 year period with an incidence of 0.49 cases per million population per year. Tumours were equally distributed between the supra- and infra-tentorial spaces. The most common symptom was headache occurring in 90%. No patient suffered seizures. Total macroscopic treatment remains the treatment of choice. Pilocytic astrocytoma of the adult is a rare tumour with a favourable prognosis.

Cauda equina syndrome: outcome and implications for management.

A retrospective review of all patients who had surgery for cauda equina syndrome (CES) due to a herniated lumbar disc between January 1996 and November 1999 was undertaken. All underwent laminectomy and discectomy, and had been admitted as emergencies with cauda equina syndrome. Ten women and 10 men with a mean age of 45 years (range 33-67) had their diagnosis verified with MRI in 19 cases and CT in one case. Only half the patients had been catheterized at the time of admission to the neurosurgical unit. Nine patients had emergency decompressive surgery within 5 h of presentation to our unit. The others had surgery on the next available list, but within 24 h of admission. No difference was found between urgently operated patients and those operated on the next available list when urological outcome and quality of life assessments were made using a validated questionnaire at a mean time of 16 months after surgery (range10-48). Twenty per cent of a control group who had undergone laminectomy and discectomy for large disc herniations, but without CES had new urological symptoms when questioned postoperatively, but similar quality of life status. Emergency decompressive surgery did no significantly improve outcome in CBS compared with a delayed approach.

Local anaesthesia for laminectomy surgery.

Neurosurgical patients presenting for laminectomy surgery may have premorbid pathology that either contraindicates general anaesthesia or at least represents a significant risk to the patient. We present a sample case from a series of ten patients in whom laminectomy surgery was performed under local anaesthesia. The mean duration of surgery was 98 minutes and the average dose of lignocaine used was 1.91 mg/kg and, therefore, within safe limits. One patient was converted to a general anaesthetic. We believe that local anaesthesia can offer a safe and satisfactory alternative, in patients who may otherwise be denied surgery. The additional advantage of awake neuro-monitoring, may also reduce the risk of inadvertant spinal cord injury.

Spinal meningiomas: a 20-year review.

The long-term outcome of 78 patients with spinal meningiomas operated on over 20 years at a single neurosurgical unit was analysed. Age, sex and tumour location were similar to those reported by others. Overall, 95% of our patents were independently mobile postoperatively, despite 25% of the group being unable to walk before operation, including four paraplegic patients. Only two tumours were entirely extradural, and a further two were both intra- and extradural. In all cases, tumour exposure was by posterior laminectomy, without recourse to more complex approaches. Complete tumour resection was achieved in 77 (98%) of cases. The dural attachment was excised in 20 cases and diathermy was applied in 58. There was one recurrence, 14 years after the original surgery. Complex and technically challenging surgical approaches are unnecessary to obtain complete removal even for anteriorly placed tumours. Excision of the dural base would seem unnecessary to attain a low recurrence rate.

Preliminary experience of carbon fibre cage prostheses for treatment of cervical spine disorders.

The objective of this study was to assess the technical feasibility, and the clinical and radiological results of interbody fusion with a carbon fibre cage following anterior cervical discectomy. Nineteen consecutive patients, eight male and 11 female, with an age range from 28 to 75 years (mean 45) underwent anterior cervical discectomy and interbody fusion with a carbon fibre cage at one or two levels. Subjective assessment of symptomatic improvement and radiological assessment of cervical spine alignment and stability was made. All complications were recorded. The procedure was technically feasible. There was no increased morbidity and the length of procedure was no longer when compared with the similar operation but using tricorticate bone graft. All patients initially lost their radicular symptoms and the patients with myelopathy had subjective improvements of their symptoms. Fourteen of the 17 patients with neck pain showed some improvement. Bony fusion was achieved in all cases.

Modification of the standard pterional approach for aneurysms of the anterior circle of Willis.

A modification of the standard pterional approach for aneurysms of the anterior circulation is described. Our technique utilizes a smaller curvilinear skin incision, splitting the temporalis and a limited craniectomy. Reduced tissue dissection results in a smoother postoperative course and improves cosmesis without compromising neurological recovery. Minimal brain retraction is required as the technique allows the surgeon to make full use of the basal opening without temporalis muscle obscuring the view.

Head injuries in the accident and emergency department: are we using resources effectively?

This paper reports a retrospective criterion based audit which reviewed head injury management in two accident and emergency (A&E) departments. Management was compared with regionally agreed criteria for ordering a skull radiograph (SXR) and a computerized tomogram (CT scan) and for admission, and the quality of medical documentation was assessed. A total of 158 patients were reviewed and 132 patients (84%) satisfied the three key areas of recommended head injury management. Failures to satisfy recommended guidelines were present in 19 patients (12%) for SXR, four (2%) for admission and three (2%) for CT scanning. Three skull fractures (two in young babies) would have been missed if the criteria had been adhered to strictly. There was one adverse outcome when a patient who should have been admitted returned to A&E 8 days after initial attendance with a subdural haemorrhage and died shortly afterwards. Apart from 'loss of consciousness', the quality both in content and legibility of the medical documentation was poor. The result of 84% correctly managed patients may be over-optimistic according to the criteria used. Although criteria have a valuable role to play, there are problems with prescriptive standard setting. A recommendation was made to develop a head injury pro forma to address the poor quality medical documentation and it was also recommended that the SXR, CT scan and admission criteria for babies and young children be reviewed.

Use of a pro forma for head injuries in the accident and emergency department--the way forward.

The aim of this study was to assess the quality of documentation of head-injured patients seen in three accident and emergency (A&E) departments using a specially designed head injury pro forma. A 4-week prospective study of a single head injury pro forma was followed by a second similar study with an improved version (two head injury pro formas, one for young children and babies, the other for older children and adults). The main outcome measures were the degree of completion of the pro forma and questionnaire responses from receptionists, nurses and doctors. A total of 1260 patients had their details completed on the pro forma in both studies. Compared with standard hand written A&E notes, the degree of completion of clinical details specific to the head injury were high, eg. over 95% for symptoms. The pro forma was generally well received by A&E staff, particularly after recommended improvements were made, and the majority of staff felt it should be introduced permanently into the A&E department. Concern about its use in cases of very minor head injury and multiple injuries were raised. As well as improved documentation, the pro forma facilitates the process of audit and may have an important role to play in information technology and computers in the future.

Radical excision of sacrococcygeal tumours.

Large sacrococcygeal tumours are rare and remain a difficult management problem. Chordomas are one of the most common tumours in this region and may account for 30-40 per cent of postrectal tumours. Four patients aged between 22 and 66 years, three with chordomas and one with a schwannoma, are described. Each was managed by a combined general and neurosurgical approach. Major radical excision of the tumour involving high amputation of the sacrum and lower sacral nerve root division was performed. These large lesions can be radically excised with limited postoperative morbidity and excellent preservation of neurological function, including sphincter control, provided that one S2 nerve root is left intact.

Diarrhea and Fecal Incontinence.

In brief Two endurance athletes developed diarrhea and fecal incontinence each time they exercised strenuously. Such gastrointestinal difficulties are usually benign, but physicians determined that the disorders were an unusual presentation of lumbar spondylolisthesis in a runner and of jejunal diverticulosis in a cyclist. The runner's diarrhea and incontinence resolved when she avoided activities that precipitated her symptoms, and the cyclist's condition resolved with oral tetracycline.

A human glioma cell line retaining expression of GFAP and gangliosides, recognized by A2B5 and LB1 antibodies, after prolonged passage.

A malignant astrocytoma was cultured from a tissue biopsy taken at surgical resection, and serially passaged 65 times over a period of 4 years. Early culture cells showed a variety of morphological types, but were all positively labelled with a polyclonal antibody directed against glial fibrillary acidic protein (GFAP). As the number of passages increased small, GFAP-positive cells became the predominant cell type. Flow cytometry demonstrated changes in GFAP expression between early and late passages; early passages showing greater fluorescence intensity than those at later passages. All cells, however, remained positive for GFAP. In addition, this line (IPSB-18) was both vimentin and glutamine synthetase positive and no change in the expression of these two proteins was detectable on continued sequential passaging. Fibronectin was not detectable at any stage. As the number of passages increased, the population doubling time was shortened from 72 h at passage 5, to 28 h at passage 30. This line is unusual in its retention of GFAP expression through 65 sequential passages; the majority of astrocytoma lines lose this capacity after a few passages in vitro. The monoclonal antibody, A2B5, which recognizes surface gangliosides, has been previously shown to identify sub-set type 2 astrocytes in normal neural tissue in vitro. The expression of A2B5 gangliosides by 5-20% of GFAP-positive IPSB-18 cells, and their co-expression with the ganglioside GD3 identified by the LB1 monoclonal antibody, shows that cells with a similar phenotype to the type 1 and type 2 astrocytes of optic nerve are present in cultured gliomas, even after long term sequential passaging.

Spinal neurofibroma presenting as atlanto-axial subluxation in von Recklinghausen neurofibromatosis.

A patient with von Recklinghausen neurofibromatosis (NF-1) developed spinal cord compression from atlanto-axial subluxation caused by a neurofibroma involving the odontoid peg. His case is discussed and the relevant literature reviewed.

Spontaneous angiographic disappearance of an intracranial arteriovenous malformation.

A deep right hemisphere AVM was demonstrated by angiography in an 8-year-old girl soon after her presentation with a subarachnoid haemorrhage. Eight years later the AVM was no longer visible on angiography. During the interval she had been completely asymptomatic and had received no treatment. There was no residual neurological deficit or epilepsy. A similar case has previously been described and is discussed briefly along with other cases of complete AVM regression.

Paraganglioma of the cauda equina: a case report.

This case report describes a paraganglioma of the cauda equina in a 63 year old woman. Very few examples of paraganglioma have been recorded in this site. Histologically these neoplasms may have considerable similarity with ependymoma, the most common neoplasm of the lower spinal cord, and the diagnosis can be easily missed unless special techniques are employed. The clinical and pathological data obtained from this and the other reported examples suggests that paragangliomas of the cauda equina are benign, slowly growing neoplasms. In contrast to ependymomas and to paragangliomas elsewhere, they are well circumscribed, amenable to complete resection and have an excellent prognosis.

Horse riding and head injury: admissions to a regional head injury unit.

A retrospective survey has been carried out of 59 patients who suffered head injury related to horse riding out of 7172 cases of head and spinal injury admitted to a regional head injury unit in the 5-year period 1980-85. Most (85%) were female, against the usual 80% male predominance of head injury, 56 were minor injuries and 3 severe, of whom 2 died. Skull fracture was present in 10 patients (17%) of whom at least 5 had been wearing headgear at impact, and scalp trauma was noted in 22 (37%) with a predominance of occipital injuries. All the severely injured cases had an occipital skull fracture. One fifth of the patients suffered additional significant injuries. While most patients (90%) made a good recovery, 2 remained moderately and one severely disabled. Horse riding posed a significant risk of head injury to the population of riders, mainly young women. This survey suggests that the wearing of amateur riding headgear does not adequately protect the rider from scalp and skull injury, particularly in the occipital region.

Motorcycling and head injury: admissions to a regional head injury unit.

In a 5-year period during which 7,178 patients with head injury were admitted to a regional head injury unit, 191 motorcyclists (2.7%) were admitted with head injuries of which 76% were classified as minor, 6% as moderate and 18% as severe (in coma). Two thirds of the patients were aged 20 years or less. Eighty-two riders (43%) had some form of facial or scalp trauma and 37 (19%) sustained skull fracture. Intracranial haematomas requiring surgical evacuation were detected in 3 of the minor head injuries (2%), 2 of the moderate injuries (17%) and 11 of the severely head injured patients (32%). Twenty-nine of the 34 severely injured patients were managed using artificial ventilation and intracranial pressure monitoring. The remaining patients died before these measures could be instituted. Overall mortality was 7%, but deaths were restricted to the severely head injured, among whom there were 13 fatalities. Head injuries associated with motorcycle riding include an unduly high proportion of severe cases and occur in a young population, often within a short time of starting to ride a motorcycle. Protective headgear was virtually always worn (94%); to reduce morbidity further, increased training and supervision during the first 6 months of motorcycle ownership should be emphasized.

Hemothorax due to rupture of a benign thymoma.

Non-traumatic hemothorax is rare and in the case we report was due to rupture of a benign thymoma. The clinical course of the patient suggested rapid intrathoracic bleeding and emergency surgery was required to make the correct diagnosis.