Idiopathic spinal cord herniation: case report and review of the literature.

OBJECTIVE AND IMPORTANCE: Idiopathic spinal cord herniation (ISCH) is a rare condition, reported in only 25 patients thus far, in which the thoracic cord is prolapsed through an anterior dural defect. It typically presents in middle age as either Brown-Sequard syndrome or spastic paraparesis. CLINICAL PRESENTATION: A 55-year-old woman initially presented at the age of 41 years with Brown-Sequard syndrome at the T8 disc space level on the left side. Investigations, including primitive magnetic resonance imaging, were deemed negative at that time. After a stepwise deterioration over 14 years, she presented again with spastic paraparesis and double incontinence, in addition to her previous spinothalamic dysfunction. Magnetic resonance imaging at this stage suggested either ISCH or a dorsal arachnoid cyst. INTERVENTION: Through a T7-T8 laminectomy, a left-of-midline ISCH was identified and easily reduced by gentle cord traction. No dorsal arachnoid cyst was identified. The anterior dural defect was repaired with a XenoDerm patch (LifeCell Corp., Woodlands, TX). After surgery, there was improved motor and sphincter function. However, there was continued sensory disturbance. CONCLUSION: ISCH is rare cause of thoracic cord dysfunction. Despite prolonged diagnostic delay, significant clinical improvement may be obtained with ISCH reduction and anterior dural repair.

Primary cerebral lymphoma--a clinico-pathological study.

A series of 18 patients with primary cerebral lymphoma (PCL) is presented. The clinical, radiological and histological findings are shown along with the results of treatment. Patients were aged 21-76 years (mean 61 years) with a male predominance of 1.6:1. Computed tomography (CT) scans were performed on 15 patients. Typically lesions were multiple, isodense, and showed uniform enhancement with contrast medium. Immunocytochemical studies demonstrated 15 B-cell and 3 T-cell lymphomas. The overall median survival from diagnosis was 3 months. Survival was improved with radiotherapy to 9 months. The difference in survival between those patients treated with surgery and steroids alone, and those who, in addition, received radiotherapy was statistically significant (p less than 0.05). We discuss the results of treatment of PCL in both this series and the literature. We also consider the increased incidence of PCL seen in this unit in 1987 and 1988 and the possible reasons for it.

Intracranial aeroceles as a complication of frontal sinus osteoma.

A case of an intracerebral aerocele as a complication of an osteoma in the frontal sinus is reported. The patient had been investigated 7 years earlier for three episodes of idiopathic nocturnal epilepsy. Roentgenograms of the skull at that time showed the presence of a small osteoma within the frontal sinus. Removal of the osteoma was undertaken via a bifrontal approach and repair to the dural defect was made with a temporalis fascia graft. Postoperatively, the patient made a good recovery but developed frequent focal left hemisphere epilepsy. It is our view that sinus osteomas that are incidentally found should be removed before complications arise.

Is the National Health Service at the edge of chaos?

We used chaos and complexity theory to analyse waiting-list data (1998-2001) pertaining to over 20 000 National Health Service (NHS) patients from general surgical, orthopaedic and neurosurgical units across England. Plots of frequency versus quarter-to-quarter change in waiting times revealed a power relation which seems independent of surgical specialty and hospital location. One interpretation of these findings is that, for the period in question, the NHS was a system at the edge of chaos. This hypothesis might explain why waiting times have resisted attempts at shortening.

Setting the standard--UK neurosurgical acoustic neuroma practice.

INTRODUCTION: The aim of this study was to determine how current practice in the UK and Ireland complies with the Clinical Effectiveness Guidelines for the Management of Acoustic Neuromas. MATERIALS AND METHODS: A survey of units and consultants using a standardised questionnaire was carried out. RESULTS: Fifty-six neurosurgeons treat acoustic neuromas in 33 out of 34 units. In 27 units, one or two surgeons specialise in this area. Caseload per annum per surgeon ranged from 2 to 30, median 15. Forty-one neurosurgeons (75%) work with an ENT surgeon. All surgeons use facial nerve monitoring during surgery. All neurosurgeons informed patients about stereotactic radiosurgery, tending to recommend it for medically unfit patients, and those with small tumours. CONCLUSIONS: Overall, 26 units (79%) and 40 surgeons (73%) met the criteria for good surgical practice. The main reasons for non-compliance were a lack of teamwork with ENT, and insufficient caseload to maintain surgical expertise.

Does posterior fossa decompression improve oculomotor and vestibulo-ocular manifestations in Chiari 1 malformation?

BACKGROUND: Oculomotor and vestibulo-ocular manifestations are associated with Chiari 1 malformation. Reports of the results of decompression of CM1 in resolution of these manifestations are limited. METHODS: A retrospective review of case notes were undertaken from Jan 1998 to March 2003 of all the cases undergoing posterior fossa decompressions by the senior author. Forty patients were identified of which 12 had oculomotor and vestibulo-ocular manifestations. RESULTS: Oculomotor and vestibulo-ocular symptoms were present in seven patients and eleven patients had clinical signs. There were only 2 patients who had symptoms and no objective findings. There was complete resolution of oculomotor and vestibulo-ocular manifestations in 8/12 patients and partial improvement in another one, leading to improvement in 9/12 patients. The mean time span to complete resolution was 15.5 months (range 3-71 months). CONCLUSION: Posterior fossa decompression appears to be highly effective in causing complete resolution of disabling oculomotor and vestibule-ocular manifestations in most cases of CM1.

Pyomyelia: an intramedullary spinal abscess complicating lumbar lipoma with spina bifida.

We report a case of spinal dysraphism, complicated by an intramedullary spinal abscess (IMSA). The magnetic resonance images of this case are shown and the pathophysiology of this condition is discussed.

The management of cerebellar abscess since the introduction of CT scanning.

Sixteen patients with surgical infection of the posterior fossa are presented. There were 14 patients with cerebellar abscess, one patient with a solitary posterior fossa subdural empyema, and another with a combined cerebellar abscess and subdural empyema. Two of the cerebellar abscess patients also had supratentorial infections. The presenting features, aetiology, radiology and bacteriology are discussed with particular reference to differences in abscess re-accumulation, and outcome between those managed by aspiration and excision. We have been unable to show that either method of treatment is superior to the other. An overall mortality rate of 19% was achieved; however, for those with parenchymal cerebellar abscesses this was reduced to 13%. We conclude that burr hole aspiration with regular CT is a satisfactory method of treatment for cerebellar abscess.

Bacillus cereus meningitis complicating cerebrospinal fluid fistula repair and spinal drainage.

Non-anthrax Bacillus species are rare, but serious causes of bacterial meningitis in those either immunocompromised or treated with CSF diversion. Although resistant to first-line antibiotics, they usually respond to chloramphenicol. We report a case of fulminant Bacillus cereus meningitis that complicated lumbar spinal drainage which proved resistant to all first-line antibiotics including chloramphenicol.

Brain abscess and hereditary haemorrhagic telangiectasia: a report of three cases.

Hereditary haemorrhagic telangiectasis (HHT) has long been viewed as a rare disease which is not usually associated with high morbidity and mortality. We report three patients with HHT who developed cerebral abscesses secondary to pulmonary arteriovenous malformations (PAVM).

Spinal cord stimulation in peripheral vascular disease.

The results of ten patients with severe, intractable symptoms of arterial disease receiving spinal cord stimulation are reported. Six out of ten patients showed clinical improvement. Three of five patients with severe rest pain obtained complete or very marked relief and one of two patients with moderate rest pain in the legs obtained complete relief. The mean claudication distance in the ten patients increased from 65 to 212 metres during epidural stimulation of the spinal cord. Exercise tolerance as measured on a bicycle ergometer increased by 61%. These changes were associated with small increases in cutaneous and muscle blood flow. In those patients who responded clinically, the improvements seen were maintained as long as spinal cord stimulation was continued. There was no clinical response to transcutaneous (placebo) stimulation and four patients did not respond in any way to spinal cord stimulation. The improvements seen are unlikely to be due to either the natural history of the disease or to a placebo effect. The effect is probably due to antidromic stimulation of the central processes of the first order sensory neurons. It is suggested on the basis of animal studies that this effect may be mediated by release of prostaglandins as well as indirectly via pain relief.

The effect of spinal cord stimulation upon peripheral blood flow in patients with chronic neurological disease.

The impact of spinal cord stimulation (SCS) upon patients with chronic neurological disease appears to be primarily upon autonomic functions. There is clinical evidence of increased blood flow in the lower limbs. In the present study, cutaneous blood flow was measured by means of xenon clearance in the legs and feet of patients receiving SCS for chronic neurological disease. In 8 patients pre-SCS cutaneous blood flow was compared with that during SCS. In 7 out of the 8 patients there was an increase in total cutaneous blood flow during stimulation. The mean pre-SCS value was 2.43 +/- 1.57 ml per 100 g of tissue and this rose to 3.23 +/- 1.81 ml per 100 g of tissue per minute during stimulation. The possible mechanisms for the increased cutaneous blood flow are discussed.