Recurrent Meningitis due to Growing Basal Skull Fracture of Orbital Roof: A Case Report

A 6-year old boy was admitted with high fever and redness of the right eyelids and the surrounding area. He had previously suffered cerebral contusion, basal skull fracture and pneumocephalus following a traffic accident which required six months' hospitalization. Since then, and prior to admission, he had twice suffered probable bacterial meningitis and had been treated at an outstanding hospital. At the time of this admission, the patient again developed high fever, with redness of the right eyelid and surrounding area. His symptomatology suggested bacterial meningitis and cerebrospinal fluid culture revealed Streptococcus pneumoniae sensitive to penicillin. In accordance with the clinical course of meningitis and accompanying sinusitis, the appropriate antibiotic and its duration of usage were determined. Recurrent episodes of bacterial meningitis in this child raised the possibility of anatomical defect as an a contributory factor. Computerized tomographic(CT) cisternography suggested leakage of cerebrospinal fluid and revealed herniated frontal brain tissue protruding through a gap in the right frontal skull base, three dimensional CT(3-D CT) confirmed this defect, which was 3X4cm in size. After recovery from meningitis, surery to prevent recurrent meningitis, was performed. To locate pathologic areas, the subfrontal approach,involving bicoronal skin incision and bifrontal bone flap was used. Multiple fracture lines and a large bony defect on the orbital roof were observed, together with a dural defect, through which cerebromalatic tissue was herniated as encephalocele. Using lyophilized dura, the dural defect was made watertight; the bony defect was packed with autologous fats and covered with titanium mesh. The patient improved after surgery. Recurrent meningitis with anatomical pathologic focus after head trauma requires surgical intervention.

Surgical Management of Atlantoaxial Instability Due to Rheumatoid Arthritis

Rheumatoid arthritis can lead to joint deformity and loss of functional capacity. The cervix may be involved, and this was first described by Garrod, in 1890. The most common abnormalities of the cervical spine found in rheumatoid arthritis patients are atlantoaxial and subaxial subluxation, and superior migration of the odontoid, the incidence of atlantoaxial subluxation is reported to be 19-17%. When signs and symptoms of spinal cord compression occur, operative stabilization is clearly indicated. Early operative fusion before evidence of appreciable neural compression occurs, is frequently recommended. Internal fixation typically involves a bone graft with Gallie-type, Brooks-type, or Dickman's interspinous fusion, or transarticular screw fixation. The purpose of this report is to describe the surgical procedures available for treatment of the rheumatoid cervical spine, the indications for surgical intervention, operative techniques, and the results in 11 patients.