Diagnosis and treatment of spinal cord herniation: a combined experience.

OBJECT: Idiopathic spinal cord herniation (ISCH) is an uncommon clinical entity typically presenting with lower-extremity myelopathy. Despite the existence of 85 ISCH cases in the literature, misdiagnosis and delayed diagnosis remain a major concern. METHODS: The authors conducted a retrospective review of patients who underwent surgery for ISCH at their institutions between 1993 and 2004. Seven patients were treated for ISCH, five in New York and two in Buenos Aires. The patients' ages ranged from 32 to 72 years. There were three men and four women. The interval between the onset of symptoms and surgery ranged from 12 to 84 months (mean 42.1 months). Preoperatively, spinal cord function in four patients was categorized as American Spinal Injury Association (ASIA) Grade D, and that in the other three patients was ASIA Grade C. In all patients a diagnosis of posterior intradural arachnoid cyst had been rendered at other institutions, and three had undergone surgery for the treatment of this entity. In all cases, the herniation was reduced and the defect repaired with a dural patch. The follow-up period ranged from 10 to 147 months (mean 49.2 months). Clinical recovery following surgery varied; however, there was no functional deterioration compared with baseline status. Syringomyelia, accompanied by neurological deterioration, developed post-operatively in two patients at 2 and 10 years, respectively. CONCLUSIONS: Patients presenting with a diagnosis of posterior intradural arachnoid cyst should be evaluated carefully for the presence of an anterior spinal cord herniation. Based on the authors' literature review and their own experience, they recommend offering surgery to patients even when neurological compromise is advanced.

Hernia medular espontanea: reporte de un caso. Revision de la literatura y teoria sobre las imagenes de IRM postoperatorias / Spontaneous spinal cord hernia. Case report, literature review and a theory about post operative MRI

Objective: to describe a new case of idiopathic spinal cord herniation. Description: a 34 year-old male patient had during the last 5 years a progressive Brown-Sequard syndrome. MRI showed ventral displacement of the spinal cord at T7-T8 and widening of the posterior subarachnoid space. Intervention: a laminectomy was performed with reduction of the herniated cord and closure of the dural defect with a graft. Postoperative outcome was uneventful and the patient improved neurologically. Control MRI showed hyperintense cord signals at the level of the previous herniated level. Conclusion: surgery with reduction of the hernia and dura closure provided symptomatic improvement. Postoperative MRI cord hyperintense signals may correspond to syringomyelia

Artritis Reumatoide con sub luxacion atlantoaxoidea: ¿es siempre necesaria la odontoidectomia? / Rheumatoid arthritis with atlantoaxial subluxation: is odontoidectomy always necessary?

Objective: to describe 3 cases of atlantoaxial irreductible subluxations (AIS) in rheumatoid arthritis (RA) and to determine the need of an odontoidectomy. Description: case 1 (60 years, female) had a chronic cervical myelopathy; case 2 (46 years, male) had and acute transitory postraumatic cervical myelopathy and case 3 had local cervical pain. Intervention: in case 1 we resected the anterior arc of C1, the pannus and the odontoid. The subluxation was reduced and a posterior occipitocervical fixation (POC) was performed. In case 2 the resection included the anterior arc of C1, the pannus and the odontoid partially because the dura was opened accidentally with the drill. In spite of it the subluxation was reduced and a POC was done. In case 3 the resection was limited to the anterior arc of the atlas and the pannus. The subluxation was reduced and a POC was performed. Conclusion: in cases of AIS with superior migration of the odontoid or retro - odontoid pannus, odontoidectomy must be performed but in cases with pre - odontoid pannus, odointoidectomy can be avoided

Rol de los corticoides en el trauma de craneo severo. Un interrogante no resuelto / Steroids rol in severe cranial trauma. A question nos answered

Objective: to evaluate the effectiveness of corticosteroids in the management of traumatic brain injury. Methods: trials concerning administration of corticosteroids to patients sustaining acute head injury were identified by means of electronic searches of MEDLINE. Articles related to pharmacology of corticosteroids, with special emphasis on potential neuroprotective activities were reviewed. Results: nineteen trials were identified, except for a few, no statistical difference in outcome or mortality between patients receiving corticosteroids or placebo. Nevertheless, a tendency was noticed towards a small number of deadths in the treated group. There was no statiscal difference between groups concerning gastrointestinal bleeding or other major complications. The analysis of the available literature on corticosteroids pharmacology provided a wide range of potentially beneficial effects through direct (receptor independent) and indirect actions, including among others, antiinflammatory, membrane stabilizing, anti oxidant and energetic metabolism protecting activities. Conclusion: corticosteroids given acutely to patients sustaining severe head injury resulted in a small but statiscally insignificant reduction in mortality. There was no significant difference between corticosteroid and control groups in mortality, nor in the rates of gastrointestinal bleeding or infection. Because of the relatively small number of patients previously enrolled in corticosteroids versus placebo trials, small reductions in mortality or deleterious effects associated with corticosteroid administration can not be excluded

Hernia medular espontanea: reporte de un caso. Revision de la literatura y teoria sobre las imagenes de IRM postoperatorias / Spontaneous spinal cord hernia. Case report, literature review and a theory about post operative MRI

Objective: to describe a new case of idiopathic spinal cord herniation. Description: a 34 year-old male patient had during the last 5 years a progressive Brown-Sequard syndrome. MRI showed ventral displacement of the spinal cord at T7-T8 and widening of the posterior subarachnoid space. Intervention: a laminectomy was performed with reduction of the herniated cord and closure of the dural defect with a graft. Postoperative outcome was uneventful and the patient improved neurologically. Control MRI showed hyperintense cord signals at the level of the previous herniated level. Conclusion: surgery with reduction of the hernia and dura closure provided symptomatic improvement. Postoperative MRI cord hyperintense signals may correspond to syringomyelia (AU)

Artritis Reumatoide con sub luxacion atlantoaxoidea: ¿es siempre necesaria la odontoidectomia? / Rheumatoid arthritis with atlantoaxial subluxation: is odontoidectomy always necessary?

Objective: to describe 3 cases of atlantoaxial irreductible subluxations (AIS) in rheumatoid arthritis (RA) and to determine the need of an odontoidectomy. Description: case 1 (60 years, female) had a chronic cervical myelopathy; case 2 (46 years, male) had and acute transitory postraumatic cervical myelopathy and case 3 had local cervical pain. Intervention: in case 1 we resected the anterior arc of C1, the pannus and the odontoid. The subluxation was reduced and a posterior occipitocervical fixation (POC) was performed. In case 2 the resection included the anterior arc of C1, the pannus and the odontoid partially because the dura was opened accidentally with the drill. In spite of it the subluxation was reduced and a POC was done. In case 3 the resection was limited to the anterior arc of the atlas and the pannus. The subluxation was reduced and a POC was performed. Conclusion: in cases of AIS with superior migration of the odontoid or retro - odontoid pannus, odontoidectomy must be performed but in cases with pre - odontoid pannus, odointoidectomy can be avoided (AU)

Rol de los corticoides en el trauma de craneo severo. Un interrogante no resuelto / Steroids rol in severe cranial trauma. A question nos answered

Objective: to evaluate the effectiveness of corticosteroids in the management of traumatic brain injury. Methods: trials concerning administration of corticosteroids to patients sustaining acute head injury were identified by means of electronic searches of MEDLINE. Articles related to pharmacology of corticosteroids, with special emphasis on potential neuroprotective activities were reviewed. Results: nineteen trials were identified, except for a few, no statistical difference in outcome or mortality between patients receiving corticosteroids or placebo. Nevertheless, a tendency was noticed towards a small number of deadths in the treated group. There was no statiscal difference between groups concerning gastrointestinal bleeding or other major complications. The analysis of the available literature on corticosteroids pharmacology provided a wide range of potentially beneficial effects through direct (receptor independent) and indirect actions, including among others, antiinflammatory, membrane stabilizing, anti oxidant and energetic metabolism protecting activities. Conclusion: corticosteroids given acutely to patients sustaining severe head injury resulted in a small but statiscally insignificant reduction in mortality. There was no significant difference between corticosteroid and control groups in mortality, nor in the rates of gastrointestinal bleeding or infection. Because of the relatively small number of patients previously enrolled in corticosteroids versus placebo trials, small reductions in mortality or deleterious effects associated with corticosteroid administration can not be excluded (AU)

Granuloma eosinofilo solitario de vertice de orbita y senos paranasales en un adulto: comunicacion de un caso y revision de la literatura / Adult solitary eosinophilic granuloma of the orbital vertex and paranasal sinuses: case report and review

Objective: to report a rare localization of Langerhans cell histiocytosis and to define its differential diagnosis and therapeutic options. Description: a 32 year-old male with derecasing visual acuity, headache and epistaxis. MRI: parasellar lytic lesion extending to nasal cavities. Transnasal biopsy: proliferation of S100 positive cells and eosinophilic granulocytes. Intervention: radiation therapy was followed by reission. Conclusion: Langerhans cell histiocytosis can present as a unifocal (eosinophilic granuloma) or multifocal sidorder. Usually affects children. The skull base is rarely affected. Surgery with or without radiotherapy is the treatment of choice for solitary accessible lesions. Isolated radiotherapy and intralesional steroids are valid options. Systemic disease requires chemoterapy

Granuloma eosinofilo solitario de vertice de orbita y senos paranasales en un adulto: comunicacion de un caso y revision de la literatura / Adult solitary eosinophilic granuloma of the orbital vertex and paranasal sinuses: case report and review

Objective: to report a rare localization of Langerhans cell histiocytosis and to define its differential diagnosis and therapeutic options. Description: a 32 year-old male with derecasing visual acuity, headache and epistaxis. MRI: parasellar lytic lesion extending to nasal cavities. Transnasal biopsy: proliferation of S100 positive cells and eosinophilic granulocytes. Intervention: radiation therapy was followed by reission. Conclusion: Langerhans cell histiocytosis can present as a unifocal (eosinophilic granuloma) or multifocal sidorder. Usually affects children. The skull base is rarely affected. Surgery with or without radiotherapy is the treatment of choice for solitary accessible lesions. Isolated radiotherapy and intralesional steroids are valid options. Systemic disease requires chemoterapy (AU)