Surgical treatment of idiopathic transdural spinal cord herniation: a new technique to untether the spinal cord.

Idiopathic transdural spinal cord herniation is a rare but treatable cause of thoracic myelopathy caused by herniation of the spinal cord through a defect in the dura. The diagnosis is frequently missed or delayed, but the latest imaging techniques can document spinal cord herniation through a dural defect. Surgical treatment, consisting of reducing the herniation by closing the dural defect or widening the aperture to prevent spinal cord compression, is rather successful. We describe a new technique to untether the spinal cord by wrapping a dura graft around the myelum to prevent recurrent transdural herniation. Two patients and a review of the literature are discussed. We conclude that high-resolution T2 magnetic resonance imaging is the best imaging modality to detect the entity, and wrapping the myelum is an effective surgical technique to untether the spinal cord.

[Too young for a twisted painful back]. / Te jong voor een pijnlijke scheve rug.

One girl aged 13 years and 2 boys aged 18 and 14 years had a painful scoliosis. Plain radiographs, blood tests and MRI revealed no abnormalities. Bone scintigraphy and CT scans were needed to establish the diagnosis 'osteoid osteoma'. In the girl, the initial CT scan was also negative and the tumours could only be found after using thin slices. She had had the complaints for 6 months and both boys had had the complaints for more than a year, before the diagnosis was made. They all made a complete recovery after surgical resection. A chronic painful back in young patients is often caused by structural deformities. The differential diagnosis also includes an osteoid osteoma. If an osteoid osteoma is suspected, then after radiographs, bone scintigraphy is indicated, which if necessary can be followed up with targeted CT scans.

[Hemicraniectomy for treatment of malignant medial cerebral artery infarction in 3 patients]. / Hemicraniëctomie als behandeling bij 3 patiënten met een maligne A.-cerebri-media-infarct.

In three patients, a 52-year old man, a 54-year old man and a 17-year old woman, sudden neurological signs such as hemiparalysis and hemihypaesthesia developed, with diminished consciousness occurring at a later stage. Imaging revealed total infarction of the area supplied by the right middle cerebral artery with the threat of intracranial hypertension. Once informed consent had been obtained from the patient's representatives, hemicraniectomy with dural augmentation was performed. Although the primary neurological deficit persisted, the three patients assessed their quality of life as valuable with their Barthel scores ranging from 45 to 90. Total infarction of the middle cerebral artery may result in intracranial hypertension and transtentorial herniation owing to the development of cytotoxic oedema, particularly in young patients. The prognosis of this condition is poor partly due to the limited effect of non-surgical treatment. Hemicraniectomy with dural augmentation prevents secondary brain damage caused by the space-occupying effect of the infarct. This operation reduces mortality considerably. The findings in these patients along with the results in the literature warrant a randomised study of the results of hemicraniectomy in patients with malignant middle cerebral artery infarction.

Does CSF outflow resistance predict the response to shunting in patients with normal pressure hydrocephalus?

The value of the measurements of CSF outflow resistance (Rcsf) relative to predicting outcome after shunting was studied. In a group of 101 patients with mainly idiopathic normal pressure hydrocephalus (NPH) Rcsf was obtained by lumbar constant flow infusion. Gait disturbance and dementia were quantified using an NPH scale (NPHS) and disability by the Modified Rankin scale (MRS). Patients were assessed before and at 1, 3, 6, 9 and 12 months after surgery. Outcome measures were differences between the preoperative and last NPHS and MRS scores. Improvement was defined as a change of > or = 15% in NPHS and > or = 1 grade in MRS. Intention-to-treat analysis of all patients at one year yielded improvement of 57% in NPHS and 59% in MRS. Efficacy analysis, excluding comorbidity unrelated to NPH, revealed positive predictive values of around 80% at Rcsf < 18, and between 90% and 100% at Rcsf > or = 18 mm Hg/ml/min. For Rcsf > or = 18, the likelihood ratios were also higher. We conclude that the best predictor of the response to shunting is an Rcsf > or = 18 mm Hg/ml/min. Since two-thirds of the patients with Rcsf < 18 showed improvement as well, these patients should not be denied shunting.

[Pott's puffy tumor]. / 'Pott's puffy tumor'.

A 26-year-old man developed a fluctuating swelling of the forehead after twice being treated with antibiotics because of persistent sinusitis complaints. This swelling, a subperiostal abcess diagnosed as 'Pott's puffy tumor', is a complication of a frontal sinusitis, and may lead to serious neurological sequelae. The patient recovered after surgical drainage, ethmoidectomy and intravenous antibiotic treatment; no ablation of affected bone was necessary.

Dutch normal pressure hydrocephalus study: baseline characteristics with emphasis on clinical findings.

We present the baseline characteristics of 101 patients with normal pressure hydrocephalus (NPH), entering a study that evaluates the diagnostic reliability of CSF outflow resistance. Patients were assessed by a gait scale consisting of 10 features of walking and the number of steps and seconds necessary for 10 m, a dementia scale comprising the 10 word test, trail making, digit span and finger tapping, the modified Mini Mental State Examination (3MSE) and the modified Rankin scale (MRS). Inclusion criteria were a gait and dementia scale ≥ 12 (range 2-40), a MRS ≥ 2 and a communicating hydrocephalus on CT. Gait disorder and dementia varied from mild to severe leading to MRS 2 in 17%, MRS 3 in 34%, MRS 4 in 21%, MRS 5 in 16% and MRS 6, including akinetic mutism, in 12%. Only one patient showed both normal tandem walking and turning. Small steps, reduced foot floor clearance and wide base were also frequently seen in the 67 patients walking independently; 34 needed assistance or could not walk at all. Applying the 3MSE, 64% were demented; the remaining 36% exhibited a milder cognitive deficit. The 10 word test and trail making decreased with increasing dementia. Digit span and finger tapping declined in the most demented patients. This group of elderly patients with NPH, mostly of the idiopathic type, proved to be vulnerable because of considerable disability and comorbidity.

Subdural hematoma after lumbar puncture: two case reports and review of the literature.

Two cases of intracranial subdural hematoma following lumbar puncture are presented. A review of all previously reported cases shows that subdural hematoma after lumbar puncture is a rare but serious complication. The pathogenesis of subdural hematoma after lumbar puncture is probably related to that of post lumbar puncture headache. Application of an epidural blood patch may therefore be a safe way not only to treat typical post lumbar puncture headache but also to prevent subdural hematoma after lumbar puncture.