Glass Fragment Injury to the Craniocervical Junction with Interatlantooccipital Penetration to the Subarachnoid Space: Not-To-Be-Missed Important Aspects of Craniocervical Trauma Even in the Middle of the COVID-19 Pandemic: Case Report and Review of Literature.

BACKGROUND: Nonmissile penetrating injuries to the craniocervical junction caused by a glass fragment are rare, and a standard management strategy has not been established. CASE DESCRIPTION: A 75-year-old Japanese man was brought into our emergency department after receiving a left retroauricular stab wound by broken glass fragments. After spinal immobilization, a computed tomography (CT) scan revealed glass fragments penetrating at the right craniocervical junction to the interatlantooccipital subarachnoid space. CT angiography showed that both vertebral arteries were not injured. Magnetic resonance imaging demonstrated that the glass fragments did not penetrate the cervical cord or medulla oblongata. These glass fragments were removed via a midline incision from the external occipital protuberance to the C7 and with laminectomy without suboccipital craniectomy. Five of the glass fragments were found and removed in total. The dural defect was patched with a free fascia autograft. His postoperative course was uneventful. Postoperative CT angiography showed that both vertebral arteries were intact and the glass fragments had been removed completely. CONCLUSIONS: CT graphical diagnosis is useful for the management of penetrating craniocervical junction trauma, and it should be considered in the evaluation of patients who have suffered craniocervical penetrating injury even in the absence of major wounds or bleeding. Spinal immobilization of patients with craniocervical penetrating injuries is crucial to avoid not only secondary neurologic damage but also secondary critical vascular damage. Incomplete or inadequate assessment of craniocervical stab wounds results in unexpected hazards that are preventable.

Incomplete oculomotor nerve palsy in the subarachnoid space caused by traumatic brain injury.

A patient with traumatic brain injury showed incomplete oculomotor nerve palsy in the subarachnoid space. A 12-year-old girl was hospitalized after a head injury. Neuro-ophthalmic examination showed that the left eye had a ptosis and pupillary involvement. An MRI indicated an intracranial hematoma at the basilar portion of the left temple. The ptosis and pupillary involvement improved after elimination of the hematoma. The presentation patterns are best explained by topographic organization of the third nerve fiber within the subarachnoid space. This case suggests that the topographic organization of the third nerve should be considered in diagnosis of oculomotor nerve palsy.

Transient lower limb pain following accidental thoracic subarachnoid insertion of an epidural catheter.

Transient sensory disturbances, including dysesthesia or neurologic deficits in the lower extremities or buttocks have been described as complications of neuraxial anesthesia. We report a case of transient lower limb pain following the accidental placement of an epidural catheter into the thoracic subarachnoid space. A 31-year-old woman was scheduled to undergo laparoscopic myomectomy. An epidural catheter was accidentally inserted subarachnoid at the T12-L1 intervertebral space with a 2-ml test dose of 2% lidocaine, and was promptly removed. Fulgurant pain and allodynia extending over the L2-5 areas of the left lower limb and buttock started immediately postoperatively. We treated the persistent pain in our patient with epidural infusion of local anesthetics and steroids during her hospital stay, and with carbamazepine and a tricyclic antidepressant after her discharge from the hospital. All signs of allodynia had disappeared on postoperative day 25. Sagittal and axial T2-weighted magnetic resonance imaging (MRI) at the Th12 level revealed a small high-intensity area without mass effect in the ipsilateral dorsal column. The patient's clinical course and MRI diagnosis suggested the inhibition of descending inhibitory pathways resulting from a lesion of the spinal cord as the possible etiology of the transient lower limb pain and allodynia.

Diagnosis and surgery of ossification of posterior longitudinal ligament associated with dural ossification in the cervical spine.

Direct removal of the ossified mass via anterior approach carries good decompression to ossification of the posterior longitudinal ligament (OPLL) in the cervical spine. Ossification occasionally involves not only the posterior longitudinal ligament but also the underlying dura mater, which increased the opportunity of the cerebrospinal fluid (CSF) leakage or neurological damage. The surgeon was required to recognize the dural ossification (DO) and need more cautious manipulation. Hida et al. first described the computed tomography (CT) findings that indicated the association with DO, and suggest the double-layer sign appeared more specific for DO. This study reviewed 138 patients who received anterior cervical corpectomy and fusion (ACCF) for OPLL, and 40 patients were found in the association with DO during anterior procedure. Radiological studies revealed that the patients with severe OPLL (higher occupying rate and larger extent) have increasing opportunity of association with DO. The double-layer sign, as a specific indicator for association with DO was sensitive in the patients with mild OPLL, but less frequent in those with severe OPLL with DO. Two surgical techniques were used for the patients with DO in anterior decompression procedure. When the double-layer sign was observed on CT scans, the OPLL could be separated from DO through a thin layer consisting a nonossified degenerated PLL to avoid CSF leakage. Otherwise, the entire ossified mass including OPLL and DO was removed completely. In this technique, the arachnoid membrane needed to be persevered with the aid of microscope to avoid a large area of membrane defect, resulting in uncontrolled CSF leakage. There was no significant difference in clinical results between the patients with DO and those without DO. Therefore, ACCF is meritorious for the patient with OPLL associated with DO, although more difficult manipulation and higher risk of CSF leakage.

Traumatic spinal-cord herniation associated with pseudomeningocele after lower-thoracic nerve-root avulsion.

BACKGROUND: Traumatic spinal-cord herniation after nerve root avulsion is rare. We report on the first patient with spinal-cord herniation associated with pseudomeningocele in the lower conus medullaris region after nerve avulsion. CASE: This 72-year-old man presented with progressive pain in the left leg and motor weakness after two traumatic accidents. Constructive interference in steady-state (CISS) imaging showed the attachment of the spinal cord to the wall of a herniated pseudomeningocele and associated syringomyelia at the level of T12. At the time of surgery, a herniated pseudomeningocele was observed. The lateral portion of the spinal cord that had herniated into the pseudomeningocele was detached from its wall; this was followed by repair of the dural defect. A redundant nerve root was observed inside the pseudomeningocele, suggesting nerve root avulsion as the primary lesion. To facilitate cerebrospinal fluid drainage from the syringomyelia, we next performed dorsal root entry zone (DREZ)tomy to the pseudomeningocele. Postoperatively, he manifested significant clinical improvement. CONCLUSIONS: This is the first report of spinal cord herniation after nerve root avulsion in the conus medullaris region. CISS imaging is highly useful for the demonstration of spinal cord herniation, syringomyelia and pseudomeningocele. To restore neurological function in patients with progressive symptoms, we recommend surgical treatment.

Malpositioned spinal instrument as a possible cause of superficial siderosis.

STUDY DESIGN: Case report. OBJECTIVE: To report a patient with superficial siderosis as a complication after posterior fixation surgery for odontoid fracture. SETTING: Department of Neurosurgery, Hokkaido University, Japan. METHODS: A 36-year-old man had undergone C1-C2 posterior fixation using lamina hooks for an odontoid fracture in 1997. In 2003, he presented with hearing loss and ataxia; and in 2006, a diagnosis of superficial siderosis was made and spinal instrument malpositioning was detected. RESULTS: The malpositioned instrument, suspected as the cause of superficial siderosis, was removed. CONCLUSIONS: Superficial siderosis of the central nervous system is rare; it results in progressive hearing loss, cerebellar ataxia and pyramidal sign. Chronic hemorrhage in the subarachnoid space precipitates hemosiderin around the cerebellum and brainstem resulting in neurological symptoms. Recurrent hemorrhage and cervical root pathology, for example, root avulsion, are factors; the symptoms worsen gradually and result in hemostasis. Superficial siderosis because of complications from spinal instrumentation surgery is extremely rare. If the instrument is malpositioned in the subarachnoid space, we suggest its removal.

Sintomatología neurológica secundaria a la migración de una bala intrarraquídea / Neurological symptoms secondary to the intraspinal migration of a bullet

Introducción. Presentamos un caso singular de la migración de una bala dentro del canal raquídeo tras una herida dorsolumbar por arma de fuego, los hallazgos radiológicos y los distintos sucesos ocurridos durante la intervención quirúrgica. Caso clínico. Varón de 28 años que dos semanas antes había sufrido una herida por arma de fuego en zona dorsolumbar. Presentó radiculopatía tardía tras la migración del proyectil desde L5-S1 a S1-S2. El paciente fue colocado en posición antitrendelenburg para poder realizar la extracción de la bala. Seis meses después de la intervención el paciente se encontraba asintomático sin evidencia de trastornos neurológicos. Discusión. La movilización de la bala en el espacio subaracnoideo, libre en el líquido cefalorraquídeo, generalmente está limitada a los segmentos entre T10 y S1 por cuestión del tamaño del canal medular. Los proyectiles pueden migrar por efecto de la gravedad según la posición del paciente. Nosotros consideramos la necesidad de extraer un proyectil intracanal, aun sin déficit neurológico, si se objetiva movilización en diferentes estudios radiográficos o tras la instauración de clínica radicular compresiva, tratándose de una cirugía urgente

Introduction. This is a very rare case of a bullet wondering into the spinal canal after a dorsolumbar firearm wound; we present the radiological findings and the problems faced at the time of surgery. Case report. The patient is a 28 year old man who had sustained a firearm wound in the dorsolumbar region two weeks before. He presented with deferred radicular symptoms after the bullet migrated from L5-S1 to S1-S2. The patient was placed in the reverse Trendelemburg position in order to extract the foreign body. Six months after the operation the patient made a full recovery with no signs of neurological damage. Discussion. The relevant literature of this uncommon condition is reviewed. Given the size of the femoral canal, the transit of the bullet in the subarachnoid space is generally limited to the movement between levels T-10 and S-1, following the laws of gravity depending on the position of the patient. We recommend extraction of a bullet present in the spinal canal, even if no neurological damage is present, if after taking sequential x-rays, the bullet is seen to migrate progressively and the patient starts reporting some radicular symptoms

New aspects in assessment of changes in width of subarachnoid space with near-infrared transillumination-backscattering sounding, part 2: clinical verification in the patient.

The study presents comparison of near-infrared light propagation and near-infrared backscattered radiation power, as simulated with numerical modeling and measured live in a patient in clinical conditions with the use of the near-infrared transillumination-backscattering sounding (NIR-TBSS) technique. A unique chance for such precise comparative analysis was available to us in a clinical case of a female patient with scalp removed from one half of the head due to injury. The analysis performed indicates that the difference between the intensity of the signals in numerical modeling and live measurements is less than 4 dB. Analysis of the theoretical model also provides hints on the positioning of the two detectors relative to the source of radiation. Correctness of these predicted values is confirmed in practical application, when changes of signals received by the detectors are recorded, along with changes of the width of the subarachnoid space. What is more, the power distribution of the spectrum of near-infrared backscattered radiation returning to the detectors is confirmed in the real recording in the patient. An abridged description of the new method of NIR-TBSS is presented.

Retropharyngeal cerebrospinal fluid collection as a cause of postoperative dysphagia after anterior cervical discectomy.

BACKGROUND: Transient dysphagia after anterior cervical discectomy is not uncommon. It is usually related to esophageal edema secondary to retraction, mechanical adhesions of the esophagus to the anterior spine, and stretch injuries to nerves involved in the swallowing mechanism. Structurally induced dysphagia, secondary to laceration of the neck viscera or to the presence of retropharyngeal masses, is by far less frequent, and it does not usually improve over time. CASE DESCRIPTION: The authors present the case of a 36-year-old woman who complained of severe dysphagia both for solids and liquids after C4 through C5 anterior discectomy and fusion, complicated by a millimetric dural tear of the anterior thecal sac. Postoperative neuroimaging revealed retropharyngeal fluid collection, extending in front of the vertebral bodies of C3, C4, and C5, exerting a mass effect on the posterior wall of the pharynx. Taking into account both the MRI aspect of the collection and the dramatic improvement of symptoms after lumbar punctures, we conducted a diagnosis of CSF collection in continuity with the subarachnoid space. The dysphagia and the CSF collection resolved with conservative therapy (bed rest and 3 lumbar punctures). CONCLUSION: To the best of our knowledge, such a complication has never been described before in the literature. It should be included in the differential diagnosis of patients with postoperative dysphagia lasting more than 48 hours.

Management of cerebral spinal fluid leak complicating spinal cord stimulator implantation.

Accidental puncture of the dura mater with resultant leakage of cerebral spinal fluid (CSF) and development of postdural puncture headache (PDPH) is a known potential complication of percutaneous placement of spinal cord stimulator (SCS) leads. However, the implications and management strategies for this complication have not been thoroughly reported. We report two cases of SCS lead placement complicated by CSF leak and PDPH.

Focal spinal arachnoiditis increases subarachnoid space pressure: a computational study.

BACKGROUND: Enlarging fluid filled cystic cavitations form within the spinal cord in up to 28% of spinal cord injured patients. These post-traumatic syrinxes can cause neurological deterioration and current treatment results are unsatisfactory. Localized scar tissue (arachnoiditis) within the subarachnoid space at the level of injury has been suggested to be involved in the pathogenesis of syrinx formation. This study tests the hypothesis that pressure pulses in the subarachnoid space are accentuated adjacent to regions of arachnoiditis, which may drive fluid into the spinal cord and contribute to syrinx formation. METHODS: An axisymmetric, cylindrical computational fluid dynamics model was developed to represent the subarachnoid space under normal physiological conditions and in the presence of arachnoiditis. Cerebrospinal fluid flow into the model was estimated from magnetic resonance imaging flow studies. Arachnoiditis was modelled as a porous obstruction in the subarachnoid space. FINDINGS: Peak fluid pressures were higher above the obstruction than in the absence of obstruction. The peak pressures were strongly dependent on the permeability of the obstruction. INTERPRETATION: Elevations in subarachnoid space pressures due to arachnoiditis may facilitate fluid flow into the spinal cord, enhancing syrinx formation. This suggests that it may be worthwhile to investigate strategies that inhibit arachnoiditis or minimize systolic pressure peaks for treating or preventing syringomyelia.

Cerebellar haemorrhage and tension pneumocephalus after resection of a Pancoast tumour.

We present an unusual case of cerebellar haemorrhage followed by tension pneumocephalus several days after thoracotomy for resection of a Pancoast tumour. The postoperative course of the 32-year-old patient was complicated by a cerebellar haemorrhage and hydrocephalus caused by compression of the fourth ventricle. Immediate surgical evacuation of the haemorrhage and placement of an external ventricular drain was performed. Respirator ventilation maintaining a continuous positive airway pressure was required. Following weaning and extubation the patient rapidly deteriorated and became comatose. A cranial CT scan revealed a dilated ventricular system filled with air, and air in the subarachnoid space. Recovery of consciousness was observed after aspiration of intracranial air through the ventricular drainage. Recurrent deterioration of consciousness after repeated air aspiration indicated rapid refilling of the ventricles with air. The patient underwent emergency surgical re-exploration of the thoracic resection cavity: dural lacerations of the cervico-thoracic nerve roots C8 and Th1 were identified. Subarachnoid-pleural fistula, cerebellar haemorrhage and tension pneumocephalus after discontinuation of continuous positive airway pressure respiration are unusual complications of thoracic surgery. We discuss the putative pathomechanisms and present a brief review of the literature.