Shunting of Syringomyelic Cavities by Using a Myringotomy Tube: Technical Note and Long-Term Results.

BACKGROUND: Syringomyelia is a progressive cerebrospinal fluid disorder that can lead to irreversible spinal cord injury. To date, the optimal management of syringomyelic cavities remains controversial. Multiple studies have emphasized the importance of the craniocervical decompression or shunting procedures; however, except for syrinx related to Chiari malformation, nearly one-half of patients need to undergo reoperation. The purpose of the present study was to describe a simple and efficient surgical technique and to report the long-term radioclinical outcomes. MATERIAL AND METHODS: We report a series of 17 consecutive patients (10 male, 7 female) with symptomatic syringomyelia treated by myringotomy tube between January 1999 and January 2014. The mean follow-up was 43.6 months (5-118). For each case, a laminectomy was carried out at the level of the most expanded part of the syrinx. The myringotomy tube was then placed through a puncture myelotomy. RESULTS: Clinical examination showed disappearance of symptoms in 3 cases, a significant improvement in 8 cases, stabilization in 5 patients, and continuation of neurologic deterioration in 1 case. Thus, favorable long-term outcomes were observed in two-thirds of patients. No permanent postoperative complication was reported. The postoperative imaging showed complete or almost complete disappearance of the syrinx in 11 cases and a reduction over 80% in 4 cases. In 2 cases, the cavity remained stable. Moreover, just 2 patients had to undergo reoperation with the placement of a syringoperitoneal shunt. CONCLUSION: A myringotomy tube is a simple surgical technique that seems to be an efficient and safe treatment for syringomyelic cavities.

Subdural motor cortex stimulation for central and peripheral neuropathic pain: a long-term follow-up study in a series of eight patients.

OBJECTIVE: In certain chronic neuropathic pain (CNP) conditions, extradural electrode implantation is preferred to a subdural location for motor cortex stimulation (MCS) therapy, but the rationale for this preference remains debatable. We provide documented long-term results of subdural MCS in CNP. METHODS: Our eight consecutive patients (five men, three women; age range, 45-81 yr) had either central or peripheral CNP. We localized the central sulcus using anatomic landmarks and three-dimensional neuronavigation and by detecting the N20 wave inversion. We then created an elongated craniotomy (3 cm long x 1 cm wide), followed by a linear incision of the dura. An eight-polar plate electrode was slipped in subdurally. We used motor-evoked potentials to choose the optimal electrode position before fixing the electrode to the dura. RESULTS: Six patients had favorable outcomes, and two had poor outcomes at the time of the last assessment (mean, 54 mo; range, 19-69 mo). Three patients experienced five transient complications, each having an episode of partial motor seizure, one that evolved into a secondary generalized seizure. Seizures were related to an abrupt increase in stimulation intensity. Two of these three patients also had hardware infections that required system replacement, with the electrode implanted extradurally at the second implantation in one case because of severe arachnoiditis. This change necessitated a greater intensity and a longer duration of stimulation to deliver a therapeutic effect equivalent to that with subdural MCS. CONCLUSION: In this small series, subdural MCS seemed a tolerable approach in the long term for CNP patients. In addition, subdural MCS provided a therapeutic effect comparable to that obtained with extradural placement.

Postoperative spinal adhesive arachnoiditis presenting with hydrocephalus and cauda equina syndrome.

To our knowledge, the association between hydrocephalus and postoperative spinal adhesive arachnoiditis (SAA) has never been reported. Herein we describe an unusual case of a 45-year-old man with spinal adhesive arachnoiditis (SAA) who developed delayed-onset hypertensive hydrocephalus and cauda equina syndrome (CES) after multiple low-back surgeries. The patient's clinical presentation, imaging findings, surgical management, and the possible mechanisms are discussed in the light of the present literature.

Stereotactic ventriculoperitoneal shunting for refractory idiopathic intracranial hypertension.

OBJECTIVE: Recent reports have shown promising short- to medium-term results in patients with refractory idiopathic intracranial hypertension (IIH) treated using the stereotactic ventriculoperitoneal shunting (SVPS) technique. However, the long-term clinical efficacy of this technique remains questionable. This report provides the long-term results of SVPS in treating refractory IIH patients. METHODS: We reviewed the medical charts of nine consecutive patients (mean age, 26.4 yr; range, 4-63 yr) treated using either a frame-based or frameless SVPS technique for IIH. RESULTS: The mean postoperative follow-up period was 44.3 months (range, 6-110 mo). Before shunting procedures were performed, each patient presented with intractable headache, and five patients (55.6%) had mild to moderate visual deficits. The last follow-up assessment showed that after shunting was performed, eight patients (89%) were headache-free. Only one patient had recurrent headache; however, this patient's pain was much less frequent and severe than before the shunting procedure was completed and was concomitant with recent weight increase. Visual deficits were resolved in three patients and remained stable in two who already had optic nerve atrophy before shunting was completed. Twelve SVPS procedures were performed on our patients. Nine shunt revisions were needed in six patients because of infection (n = 5, including two revisions in one patient), valve dysfunction (n = 2), distal obstruction (n = 1), and ventricular catheter malpositioning (n = 1). No patient had proximal catheter obstruction. CONCLUSION: Given the favorable long-term outcome of the SVPS technique for refractory IIH, we are encouraged to apply this procedure on our patients. More invasive approaches should be reserved for patients who have SVPS failure.

Deep EEG recordings of the mammillary body in epilepsy patients.

PURPOSE: To our knowledge, the epileptic and nonepileptic electroencephalographic (EEG) discharges recorded within the human mammillary body (MB) and mammillothalamic tract (MTT) areas have never been published. Herein, we present the EEG recordings from these structures in patients with refractory epilepsy (RE). METHODS: Three men (ages 41-43 years) were enrolled in a clinical trial for deep brain stimulation (DBS) of MB-MTT in RE. Previous evaluations had demonstrated a low likelihood of successful response to medication or resective surgery. DBS macroelectrodes were bilaterally implanted within the MB-MTT under general anesthesia and their location checked by magnetic resonance imaging (MRI). We obtained a surface-depth EEG for a 2- to 4-day period, including monitoring of the cardiorespiratory and mnemonic functions. RESULTS: The background pattern of EEG recorded from MB-MTT was low-amplitude (usually <25 microv for MB and <20 microv for MTT) waves with a variable combination of theta-beta rhythms. In two patients, pseudoperiodic slow spikes were unilaterally recorded with or without clinical signs. For one patient, several focal ictal discharges were recorded in the right MB without scalp EEG changes. CONCLUSIONS: The analysis of our depth EEG revealed that the theta-beta pattern represents the predominant physiologic profile of MB. Paroxysmal epileptiform discharges can be observed in human MB. These data supplement those available from animal observations.

Epileptic discharges in a mammillary body of a patient with refractory epilepsy.

Objectives. To document epileptiform discharges recorded within a mammillary body (MB) of a patient with chronic refractory epilepsy (CRE). Materials and Methods. A 37-year-old man, whose epilepsy was not controlled by medication or vagus nerve stimulation, was enrolled in a study of the effects of deep brain stimulation of the MB and mammillothalamic tract (MTT) in CRE. Surface and deep EEG recordings were obtained for 3 days before implantation of the macroelectrodes and for 4 days after implantation of the macroelectrodes but before implantation of the stimulator battery. Results. Paroxysmal epileptiform discharges were recorded in the right MB while other surface and deep recordings, in particular from the right MTT, were silent. When these discharges were longer than 100 sec, they spread to the right MTT area and then to the left MB and MTT area. Simultaneously, the patient became agitated and confused. Conclusions. This original observation indicates that subcortical neuronal structures, such as the MB, may sustain epileptiform discharges in humans.