L1/2 Intradural Disc Herniation with Compression of the Proximal Cauda Equina Nerves: A Surgical Challenge.

BACKGROUND: Intradural disc herniation (IDH) in the upper lumbar spine is rare. Preoperative radiologic diagnosis can be difficult, making operative planning challenging. We report on a 74-year-old female patient who was diagnosed with an L1-L2 IDH intraoperatively. This case report aims to highlight and discuss the radiological features of IDH and operative challenges when approaching IDH. CASE DESCRIPTION: A 74-year-old female patient presented to outpatient clinic with a 3-month history of significant intermittent neurological claudication and severe lumbar back pain. Her examination was unremarkable apart from a positive left-sided femoral stretch test. Magnetic resonance imaging (MRI) revealed a large central L1/L2 disc herniation causing significant compression of the thecal sac and proximal cauda equina nerve roots. She underwent an elective posterior L1/L2 lumbar exploration. Intraoperatively, identification of the disc was difficult, which led to inadvertent cerebrospinal fluid leak after incision of what was thought to be a disc bulge. Further exploration revealed an intradural disc that was removed via durotomy. The thecal sac was repaired with sutures and TISSEEL (Baxter, Deerfield, Illinois, USA). Postoperatively, the patient complained of weak left lower limb; MRI revealed residual disc remnants causing compression of the cauda equina. She successfully underwent an urgent revision decompression procedure. She was discharged to rehabilitation on postoperative day 14 with weakness in left knee flexion and extension (MRC grade 4/5) and left ankle plantar- and dorsiflexion (MRC grade 2/5). CONCLUSIONS: Upper lumbar IDH represent a surgical challenge. Intraoperative considerations include identification of the disc, intentional or incidental durotomy, intradural discectomy, and anatomical restrictions of operating at the level proximal to the cauda equina.

Adult Parasellar Capillary Hemangioma with Intrasellar Extension.

BACKGROUND: Capillary hemangiomata are benign vascular tumors that typically occur in children. They rarely occur in the central nervous system. Intracranial capillary hemangiomata in adults are very rare entities with only 18 cases reported in the literature. We report a case of parasellar capillary hemangiomata that extended into the sella in a 64-year-old woman as well as a review of the literature in adults. CASE DESCRIPTION: We report a 64-year-old patient who presented with a headache, left-sided paresthesia, and weakness. Initial computed tomography of her brain showed a left-sided 3 cm × 2.5 cm parasellar lesion with intrasellar extension and no mass effect. Subsequent magnetic resonance imaging (MRI) showed a lesion that was homogenously hyperintense on T2-weighted MRI and fluid-attenuated inversion recovery, isointense with adjacent brain parenchyma on T1-weighted MRI, and which demonstrated enhancement after contrast administration. The patient initially underwent an endoscopic transsphenoidal biopsy, which was inconclusive, followed by a craniotomy, biopsy, and debulking. Histologic examination showed fibrous tissue containing numerous thin-walled and irregular vascular channels of varying sizes. There was a very mild associated inflammatory infiltrate, mainly formed of small mononuclear chronic inflammatory cells and occasional histiocytes. The histologic appearances were in keeping with capillary hemangiomata. CONCLUSIONS: Capillary hemangiomata related to the sella are very rare and can easily be misdiagnosed on imaging alone. The present case highlights capillary hemangiomata as an important, albeit rare, differential when considering a sellar or parasellar mass.

Calcifying Pseudoneoplasm of the Neuraxis: A Case Illustrating Natural History over 17 Years of Radiologic Surveillance.

BACKGROUND: Calcifying pseudoneoplasm of the neuraxis (CAPNON) is a rare central nervous system lesion that can occur in both the brain and the spine. Although this entity is poorly understood, radiologic and histological features have been identified. CASE DESCRIPTION: We report a unique case of a 31-year-old patient who was managed with antiepileptic medication for 17 years before requiring neurosurgical intervention for tumor progression. T2-weighted magnetic resonance imaging revealed hyperintensity within the tumor with extensive associated vasogenic edema, which is not normally associated with CAPNON. Resection was successful with no complications. CONCLUSIONS: The present case illustrates the long-term natural history of CAPNON before resection and highlights the variations in radiologic appearance that may be associated with this poorly understood entity.

Intracranial Hypotension Following Traumatic Brain Injury: A Diagnostic and Therapeutic Challenge.

BACKGROUND: Intracranial hypotension (IH) is a recognized cause of coma; however, the diagnosis is often challenging, especially in patients with superimposed traumatic brain injury. CASE DESCRIPTION: A 67-year-old woman became comatose following evacuation of bilateral acute subdural hematomas with concurrent respiratory failure. Imaging and intraparenchymal intracranial pressure monitoring confirmed secondary IH. She was managed with an epidural blood patch and a 72-hour period in the Trendelenburg position guided by intracranial pressure monitoring and clinical assessment. She subsequently made an excellent neurologic recovery from an initial Glasgow Coma Scale score of 3 to a score of 15. CONCLUSIONS: Secondary IH can easily be missed in patients who have sustained a primary brain injury. In patients with a poor neurologic recovery, clinicians should rule out secondary IH as a potential cause, as immediate treatment can lead to profound clinical improvement.

Pilot study of perioperative accidental durotomy: does the period of postoperative bed rest reduce the incidence of complication?

INTRODUCTION: An accidental durotomy is a recognised and not infrequent complication of lumbar spine surgery, and may lead to postoperative low-pressure headaches, pseudomeningocele and CSF leak. Conventional postoperative management involves a period of flat bed rest. There is no agreement as to the need for and duration of postoperative bed rest. This study aims to determine whether the duration of flat bed rest alters the rate of these complications. MATERIALS AND METHODS: This is a retrospective study. All patients who underwent surgery for degenerative spinal disease between May 2010 and May 2011 were reviewed. All patients who incurred an accidental durotomy and who were repaired using fibrin glue were included in this study. Their notes were reviewed for evidence of complications for a minimum of 12 months after surgery. The following complications were identified: postural headache, pseudomeningocele, CSF leak wound infection, subdural haematoma. RESULTS: Eight hundred and eighty-nine patients underwent lumbar spine surgery. Sixty-one (6.8%) patients suffered an accidental durotomy and were repaired with fibrin glue. Twenty-six patients were mobilised on the first postoperative day, 9 patients on the second, and a further 26 patients were mobilised on the third postoperative day or later. The overall incidence of complications related to the durotomy was 18%. There was no statistical significance between the day of mobilisation and the rate of complication (p = 0.433). CONCLUSION: A longer period of mandatory bed rest does not decrease the rate of complications. Patients should be mobilised as soon as they can. This could potentially reduce the length of hospital stay and the cost of aftercare.