A Proposed Intention-to-Treat Anatomical Classification of Spinal Dural Tears.

To clarify outcomes and develop a novel classification according to CSF fistula in a selective cohort with intraoperative spinal dural tear, we examined 72 consecutive patients who underwent spinal dural repair after microdiscectomy (n=42) or lumbar spinal decompression (n=30). Group 1 consisted of 25 patients with Type I (mild) dural tear who were treated with either tissue-glue-coated collagen sponge or fibrin glue. Group 2 consisted of 26 patients with Type II (moderate) dural tear who were treated with both tissue-glue-coated collagen sponge and fibrin glue. Group 3 consisted of 21 patients with Type III (severe) dural tear who were treated with polypropylene suture along with tissue-glue-coated collagen sponge and/or fibrin glue. Evident postoperative internal or external CSF leak was used to determine the patient's postoperative result. Postoperative internal or external CSF leak was not evident during a minimum 1-year follow-up in Group 1. In contrast, internal CSF leak was evident in both Groups 2 (n=3) and 3 (n=3) during the same follow-up. No external CSF leak was noted in any of the patients. Three patients underwent re-do spinal surgery for CSF leak repair. Patients in all groups satisfactorily avoided CSF leak. According to the intraoperative findings of a distinct dural tear, patients can be treated adequately with a specific surgical technique.

Evaluation and management of small dural tears in primary lumbar spinal decompression and discectomy surgery.

Incidental dural tear is one of the most common intraoperative complications in lumbar spine surgery. Yet, its technical management for the prevention of CSF leak is controversial. The technique of managing dural tears depends on the location of the dural tears as well on the length and anatomical characteristics of the dural tear. We propose an anatomical classification for small (less than one cm) dural tears and report on the outcome of managing these dural tears types using different technique for different type. 62 patients underwent spinal dural repair after microdiscectomy or lumbar spinal decompression. Group 1 consisted of 20 patients, with Type I or mild dural tear who had tissue-glue coated collagen sponge or fibrin glue application. Group 2 comprised 21 patients with Type II or moderate dural tear who had both tissue-glue coated collagen sponge and fibrin glue application. Group 3 comprised 21 patients with Type III or severe dural tear who had polypropylene suture and tissue-glue coated collagen sponge and/or fibrin glue application. Evident postoperative CSF leak was used to determine the patient's postoperative result. Postoperative CSF leak was not evident during a minimum 1 year follow up in group 1. Internal CSF leak was evident in group 2 (n = 3) and group 3 (n = 3) during same follow up. Three patients underwent re-do spinal surgery for CSF leak repair. We recommend different management technique depending on the type of tear. For type I, we recommend the use of tissue-glue coated collagen sponge or fibrin glue application, without dural suturing.

Intracranial hemorrhage following surgery for occult spinal dysraphism: a case-based update.

BACKGROUND: Intracranial cerebrospinal fluid (CSF) volume depletion causes diverse clinical syndromes most of them constituting the manifestations of decreased intracranial pressure. Subdural collections or chronic subdural hematomas are the best-known consequences of persistent CSF leaks, especially in overshunted hydrocephalus. Continuous CSF escape also occurs after lumbar puncture, spinal anesthesia, and diverse spinal surgeries. CASE DESCRIPTION: A 6-year-old boy submitted to reoperation of spinal cord compression due to partial sacral agenesis complained of postoperative orthostatic headaches and vomiting initially attributed to CSF hypotension. There were neither subcutaneous fluid accumulations nor CSF leakage from the wound. The child was treated with strict bed rest and intravenous hydration for 5 days. On reassuming orthostatism, the patient had syncope but did not hit his head. A cranial computerized tomography scan showed an acute subdural hematoma that was managed conservatively with total recovery. DISCUSSION AND CONCLUSION: A review of current literature showed scanty reports of acute intracranial bleeding occurring after CSF depletion following spinal surgical procedures. To our knowledge, our reported patient represents the second case of this occurrence following surgery for closed spinal dysraphism in a child. The authors briefly review documented instances of acute subdural hematoma following spinal procedures, advise about its diagnosis, and suggest preventive measures.

Management of neonatal hydrocephalus: feasibility of use and safety of two programmable (Sophy and Polaris) valves.

BACKGROUND: Neonates represent a unique group of pediatric patients with special peculiarities. Hydrocephalus valves have not always been designed to meet the requirements of these small children. Few series have addressed the problem of cerebrospinal fluid shunting in newborn babies. OBJECTIVES: We aimed (1) to evaluate the feasibility of the use of two programmable valves (Sophy and Polaris) in hydrocephalic neonates and (2) to ascertain complications and safety issues arising from their use. MATERIALS AND METHODS: We performed a prospective study of 100 consecutive preterm and term babies (<2 months of age) given a programmable valve. Valves' settings were readjusted at different pressure levels as required. Outcomes were obtained from the records of our Outpatient Clinic. RESULTS: The study group was formed by 60 term and 40 preterm infants (average weight 2,440 g, mean age of 25 days). Mean follow-up was 55 months. Only one fifth deaths was shunt-related. In 70 babies, no complications occurred, and hydrocephalus was successfully controlled. Proximal catheter obstruction presented in 20% and infection in 5% of cases. Several external adjustments of the valves apparently avoided several surgical shunt revisions. CONCLUSIONS: (1) Both programmable valves (Sophy and Polaris) can be safely used for treatment of neonatal hydrocephalus, introducing some technical modifications. (2) Both valves are comparable to other shunts with regard to indications, performance, and safety. (3) The possibility of modifying their working pressure seems to constitute their main advantage. Prevention of late overdrainage syndromes with these valves needs a longer follow-up.

Cauda equina-penetrating injury in a child. Case report.

The authors report the case of a 10-year-old boy who sustained an injury to the cauda equina as a result of the accidental penetration of a wooden pencil into the spinal canal. After neuroimaging evaluation to exclude visceral and vascular lesions, the foreign body was removed and the wound was repaired. This is the first report of a cauda equina injury caused by a pencil.

Functional assessment of intracranial arachnoid cysts with TC99 m-HMPAO SPECT: a preliminary report.

BACKGROUND: Many arachnoid cysts (AC) are detected incidentally in asymptomatic patients. Current neuroimaging methods provide only morphological details of the cysts, but they do not give information about cerebral function. While surgery is indicated in symptomatic patients, the management of asymptomatic individuals, who present with large cysts, is controversial. STUDY OBJECTIVE: To ascertain the value of cerebral 99 mTc-HMPAO single photon emission computed tomography (SPECT) for detecting brain dysfunction in cases of intracranial ACs, aimed at allocating the patients for surgical or for conservative treatment. PATIENTS AND METHODS: We studied prospectively 11 patients diagnosed with sylvian fissure ACs. The subjects underwent neurological examination, EEG, neuroimaging studies, neuropsychological testing, and cerebral perfusion studies with 99 mTc-HMPAO SPECT. RESULTS: The patients' ages ranged from 2 to 42 years (median 16 years). The study group consisted of ten symptomatic patients with ACs and one patient with an incidental cyst. Seven patients showed diminished regional cerebral blood flow (rCBF) in their initial cerebral SPECT. Four individuals underwent surgery. Seven patients showed normalization of rCBF after surgical or conservative treatment. CONCLUSIONS: Cerebral SPECT demonstrated impaired brain perfusion in 70% of symptomatic patients. The zone of decreased rCBF corresponded well with clinical symptoms and with neuroimaging findings. Patients exhibiting normal rCBF in SPECT studies remained or became asymptomatic during the follow-up time. Cerebral SPECT constitutes a valuable adjunct tool for correlating regional function with brain anatomy, and may be of help to allocate patients with ACs for surgical treatment or clinical observation. Further research on this field is warranted.

Platelet GP IIIa polymorphism HPA-1 (PlA) protects against subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Few genetic modifications have been identified to be associated with subarachnoid hemorrhage (SAH), most of them playing a role in the formation or size of aneurysms. METHODS: We evaluated the role of common and functional polymorphisms affecting the main platelet adhesive glycoproteins (GP) (GPIIIa: HPA-1; GPIa: HPA-5 and C807T; GPIbalpha: HPA-2 and VNTR) in the risk for development of the disease and in the severity of the onset. The study was performed in 103 patients with SAH, 103 matched controls, and 473 subjects from the general population. RESULTS: The HPA-1b (PlA2) allele significantly protected against SAH (OR, 0.48; 95% CI, 0.24 to 0.96; P=0.037). Interestingly, patients carrying this allele displayed larger aneurysms, but the extension of their hemorrhage and the clinical grade at presentation was significantly lower when compared with patients HPA-1 a/a (11.9+/-2.8 mm versus 8.8+/-2.2 mm, P=0.0001. Fisher grade < or =2: 68.4% versus 20%; P=0.0001; Hunt and Hess score

Inflammatory atlanto-axial subluxation (Grisel's syndrome) in children: clinical diagnosis and management.

BACKGROUND: Grisel's syndrome is a uni- or bilateral subluxation of the atlas on the axis associated with an inflammatory condition of the head or neck. This uncommon entity usually affects children. The condition seems to be secondary to hyperemia and laxity of the atlanto-axial joints. PATIENTS AND METHODS: We report clinical and neuroimaging findings, treatment modalities, and outcomes in 4 children with atlanto-axial rotatory subluxation (AARS) associated with a previous upper respiratory tract infection treated at our Unit during the last 7 years. RESULTS: All children presented with neck pain, head tilt, and reduced neck motion. In 3 patients, the condition was secondary to otitis media and in the remaining patient to viral pharyngitis. The diagnosis was established by clinical signs and symptoms and confirmed by neuroimaging studies, especially by computerized tomography and 3-D reconstructions. Early detection and treatment resulted in a good outcome in all patients. None of the patients required surgical treatment. CONCLUSIONS: Grisel's syndrome must be suspected in children with painful torticollis associated with an upper tract respiratory infection. The best results are obtained with early conservative treatment, which prevents chronic changes leading to persistent neck pain and deformity, namely atlanto-axial rotatory fixation (AARF). We emphasize the fact that the diagnosis of Grisel's syndrome is mainly clinical, while the diagnostic confirmation of AARF can only be attained by special neuroimaging techniques.

Polymorphisms of platelet adhesive receptors: do they play a role in primary intracerebral hemorrhage?

BACKGROUND: Several reports suggested that polymorphisms affecting the structure or level of the main adhesive platelet glycoproteins (GPs) could behave as genetic risk factors for arterial thrombotic disorders. However, very few reports analyzed the significance of these polymorphisms in bleeding disorders. Interestingly, one study suggested a role of the 807 C/T polymorphism of the collagen receptor GP Ia in the severity of the bleeding manifestations in von Willebrand disease. The aim of this study was to evaluate the role of frequent polymorphisms affecting platelet GPs in primary intracerebral hemorrhage (PIH), the third most frequent cause of cerebrovascular disorder. METHODS: We evaluated the role of four putative prothrombotic polymorphisms: GP Ia [807 C/T, and human platelet alloantigen system 5 (HPA-5)], GP Ibalpha (variable number of tandem repeats), and GP IIIa (HPA-1) in 141 Caucasian patients diagnosed of PIH, 141 race-, age-, sex- and risk factor-matched controls, and 446 subjects from the general population. RESULTS: The frequency of genotypes and alleles were similar between patients and controls. CONCLUSIONS: Our results suggest that these polymorphisms play a minor role in PIH.