Intramedullary neurenteric cysts of the spine. Case report and review of the literature.

This case of a 68-year-old woman with a low-thoracic intramedullary neurenteric cyst is notable for clinical presentation, cyst location, intraoperative findings, and imaging characteristics. The patient's postoperative course was complicated by neurological deterioration and a neuropathic pain syndrome. Potential causes of these complications are discussed, as are possible ways to reduce the risk of their occurrence.

Radiologic evaluation in patients with head injury.

Head injury is common. With many excellent imaging techniques readily available, radiologic evaluation has become critical in the management of patients with head injuries. We review the indications for various imaging studies in patients with head injury. In general, a noncontrast computed tomography of the head is the study of choice for patients with head injury and should be performed whenever there is reasonable suspicion of a serious injury to the brain.

Vertebral arch or posterior spinal tuberculosis.

Posterior spinal tuberculosis or arch tuberculosis is a form of skeletal tuberculosis that selectively involves the vertebral arch. It may mimic skeletal neoplasm clinically and radiographically. Although posterior spinal tuberculosis has been reported in developing countries it has rarely been found in the United States. As a result, there is limited information about this entity in the US literature. We are presenting our experience in a patient born in the United States.

Cervical epidural hematoma after chiropractic manipulation in a healthy young woman: case report.

OBJECTIVE AND IMPORTANCE: Posttraumatic spinal epidural hematoma is an uncommon entity. We present the first report of spinal epidural hematoma occurring after chiropractic manipulation in a healthy young adult without preexisting cervical disease or any obvious predisposing factors. CLINICAL PRESENTATION: The patient presented with radicular and myelopathic symptoms that developed 15 minutes after chiropractic manipulation. Computed tomography and magnetic resonance imaging were performed. They revealed a cervical epidural hematoma. INTERVENTION: The hematoma was evacuated, and all of the patient's neurological symptoms improved over the course of the next 3 days. CONCLUSION: Although cervical spinal epidural hematoma is a rare clinical entity, it must be considered in patients with pain or neurological deficit after cervical trauma.

Giant cell tumour of the seventh cervical vertebra.

A 43-year-old man presented with bubbly expansion and rarefaction of the body of the seventh cervical vertebra. The lesion involved the right side of the vertebral arch and had a soft-tissue component extending mainly anterior to the vertebra. Histopathologic examination of the specimen obtained by open biopsy revealed a giant cell tumour. Giant cell tumours of the spine, excluding the sacrum, are rare. Radiographically, they may be confused with metastatic carcinoma, plasmacytoma, lymphoma, chordoma and even benign lesions, particularly aneurysmal bone cyst and brown tumour of hyperparathyroidism. However, giant cell tumour occurs mainly in younger patients, involves the vertebral body selectively in most cases and has a bubbly appearance associated with rarefaction and expansion of the vertebral body, characteristics that may be helpful in the diagnosis.

Symptomatic cavernous malformations affecting the spine and spinal cord.

Ten cases of symptomatic cavernous malformations affecting the spine and spinal cord were retrospectively reviewed. The cases display a spectrum of pathological findings involving the vertebral body, vertebral body with epidural extension, epidural space without bony involvement, intradural extramedullary space, and intramedullary lesions. Lesions at all locations are identical histologically, electron microscopically, and immunohistochemically. This perspective, in which cavernous malformations are envisioned as a single entity arising at numerous locations, runs contrary to the view found in the neurosurgical literature. In most discussions of cavernous malformations, vertebral body lesions are depicted as separate entities from intradural lesions. Cavernous malformations, also called cavernous hemangiomas, are developmental vascular hamartomas that, by definition, do not grow by mitotic activity. Yet, the expansion of these lesions is well documented both in the literature and among our cases. The therapeutic modalities used in our series included observation, embolization, radiation, and surgical resection alone or in combination. All modalities are effective but must be tailored to the specific needs and condition of the patient. The embryology, methods of treatment, and proposed mechanisms of growth, plus similarities and differences between cavernous malformations at each location, are reviewed. Analogies between spinal and intracranial lesions are presented. On the basis of this series and a review of the literature, we conclude that cavernous malformations represent a single entity regardless of location. Segregation based on location, as is prevalent throughout the neurosurgical literature, hinders an overall understanding of these lesions. Cavernous malformations are more appropriately viewed as a single pathological entity arising in a multitude of locations. The difficulties encountered when managing cavernous malformations at various locations are unique to the location and not the lesion.

Complications of cervical disk surgery.

The common complications of cervical disk surgery using the posterior and the anterior approach are discussed. The advantages and disadvantages of diskectomy with and without fusion are also presented. Complications of cervical disk surgery are a function of the type of procedure, the specific anatomic approach, and the experience of the surgeon. Although the posterior approach may be used for posterolateral or lateral herniated disks and foramenal osteophytes, the anterior approach is safer for central herniated disks and osteophyte formation. At The Mount Sinai Hospital, anterior-approach cervical diskectomy, whether with or without fusion, is preferred to the posterior approach for all herniations.

Predicting outcome in brain-injured patients. Using the Glasgow Coma Scale in primary care practice.

The Glasgow Coma Scale provides a quick and simple way to assess the level of consciousness of a brain-injured patient and to predict that patient's social outcome. The information provided by such prediction of prognosis can help primary care physicians choose the appropriate therapeutic regimen and also allows investigators to compare alternative regimens.

Osseous lesions of the cervical spine.

Osseous lesions of the cervical spine present a spectrum of histopathology varying from benign to highly malignant tumors. Vertebral body resection and reconstruction are possible at all levels of the cervical spine. This affords decompression of the spinal cord even with anterior or anterolateral masses. Resection of the posterior arch or vertebral body should be followed by internal fixation with Halifax clamps, Roy-Camille plates, or Ransford rods posteriorly with a bony fusion or by Caspar plates, strut grafts, or acrylic anteriorly. Restoration of spinal alignment must be carefully planned to correct any structural deficits. In those patients who are not considered as surgical candidates, steroids, chemotherapy, or radiation remain effective alternatives in attempting to relieve pain or reverse neurologic deficits. Earlier awareness and evaluation for this group of patients will afford relief of pain, reversal of neurological deficits, stabilization of the cervical spine, and early immobilization.

Paranasal sinus disease with intracranial extension: aspergillosis versus malignancy.

Aspergillus is a fungus with world-wide distribution and a common endogenous contaminate of the upper respiratory tract. It has become an increasingly recognized pathogen in the paranasal sinuses. In its pathologic state it presents in one of several forms that may represent a continuum of the disease: allergic, noninvasive, invasive, and fulminant. The progression and prognosis of these disease depends on the location and immunologic status of the patient. This case represents the fourth reported case of a nonimmunologic compromised patient with intracranial extension of aspergillosis. The patient presented with unilateral pansinusitis and radiographic evidence of orbital and anterior cranial fossa invasion. This case illustrates the difficulty of establishing the diagnosis of invasive aspergillosis and differentiating it from neoplastic entities. Radiographs and photomicrographs will be presented to establish this premise.

Thoracic disc disease. Clinical manifestations and surgical treatment.

Thoracic disc herniation in an uncommon spinal entity. The authors discuss three variations in the presentation of the disease and point out the importance of being able to recognize both the thoracic prolapsed disc and the symptomatic degenerated nonherniated disc. The seven cases that are reported demonstrate the unique presentations of this disease and the techniques for treatment. Utilization of the anterior transthoracic approach for the excision of the herniated disc is emphasized.

Pressure-absorption responses to the infusion of fluid into the spinal cord central canal of kaolin-hydrocephalic cats.

The resistance to cerebrospinal fluid (CSF) absorption through the alternative CSF absorption pathway in kaolin-induced hydrocephalic cats was measured by the constant infusion-manometric test. The cerebral ventricles were bypassed, and artificial CSF was infused directly into the central canal of the spinal cord. The infusion rates were increased stepwise from 0.022 to 0.168 ml/min when the capacity to absorb CSF was exceeded. There was an initial increase in resistance which was associated with the emergence of infusion fluid through a slit-like opening in the dorsal columns of the lower lumbar spinal cord. The resistance to flow decreased when the infusion rate was greater than 0.086 ml/min. Fluid accumulated in the spinal subarachnoid space when the ability to absorb was exceeded. The diversion of this fluid caused the pressure in the spinal cord central canal to fall rapidly. The results suggest that the CSF absorption deficit in chronic kaolin-induced hydrocephalic cats is probably caused by the restriction of CSF flow from the central canal through the spinal cord and into the spinal subarachnoid space. As a result of kaolin, the central canal is sufficiently dilated to permit, during infusion, the flow of at least five times as much CSF as the hydrocephalic cats produce. It is not clear whether the overloading of the CSF absorption mechanism is due to the restrictions imposed by the size of the subarachnoid space, or to the structures in this space involved with the return of CSF to the blood.

The rat in experimental obstructive hydrocephalus.

The effects of kaolin-induced hydrocephalus on CSF turnover was studied in rats by ventricular perfusion and the results compared to normals. The mean CSF formation rate measured in 20 normal rats was 2.83 microliter/min. Approximately three weeks after intracisternal kaolin, the mean CSF formation rate in 17 hydrocephalic rats was reduced by 40%. CSF absorption in hydrocephalic and normal rats varied linearly with perfusion pressures between -10 and 10 cm H2O. The response of CSF absorption rate to changes in intracranial pressure was decreased in hydrocephalic rats. Ventriculomegaly of hydrocephalic rats was associated with a dilated spinal cord central canal. This suggests that kaolin hydrocephalus alters CSF pathway in rats in a manner similar to that described previously in cats and dogs. Ventriculomegaly is limited by the supporting structures of the brain because the removal of the calvarium and dura after kaolin results in massive ventriculomegaly.

Chondrosarcoma of the spine.

Involvement of the spine by chondrosarcoma is rare. Three recent cases involving the cervical with or without extension to the thoracic spine are reported. Detailed radiologic investigations to evaluate the extent of the disease are essential to management. Computerized axial tomography and angiography were performed in 1 case and were extremely helpful. Surgical resection of the lesion is the only currently effective method of treatment, but long-term survival figures are not good.