Internal neurolysis of the maxillary branch of the trigeminal nerve for the treatment of equine trigeminal mediated headshaking syndrome.

A 5-year-old Hannovarian warmblood gelding was presented for recurrent headshaking exacerbated with exercise. The horse displayed clinical signs of repetitive vertical head movements, face rubbing on the forelimbs and on the ground, repetitive sneezing, and striking the muzzle with his forelimbs. The clinical signs resulted in a horse that could not be ridden and was dangerous. Clinical signs were most persistent in direct sunlight, but occurred with excitement, exercise, or bridling indoors. A diagnosis of equine trigeminal mediated headshaking syndrome was made. Surgical treatment was performed with a supraorbital approach to the maxillary branch of the trigeminal nerve as it exits the round foramen, where an internal neurolysis (nerve combing) was conducted on both the left and right nerves. Severe headshaking behavior resolved after surgery. The horse displayed face rubbing of the muzzle which began 96 hours after surgery and resolved over 12 days with corticosteroid and vitamin E therapy. The horse became pasture sound and the clinical signs had resolved in the presence of sunlight, but repetitive vertical head movements persisted under saddle which left the horse unpleasant to ride.

Neurolyse interne de la branche maxillaire du nerf trijumeau pour le traitement du syndrome équin de hochement de tête à médiation du trijumeau. Un hongre hanovrien warmblood âgé de 5 ans a été présenté pour un hochement de tête récurrent exacerbé par l'exercice. Le cheval a manifesté des signes cliniques de mouvements verticaux répétitifs de la tête, du frottement de la face sur les jambes avant et sur le sol, des éternuements répétitifs et le frappement du museau avec les jambes avant. Les signes cliniques se sont traduits par un cheval qui ne pouvait pas être monté et était dangereux. Les signes cliniques étaient les plus persistants à la lumière du soleil directe, mais se produisaient lors d'un état d'excitation, de l'exercice ou avec la bride à l'intérieur. Un diagnostic de syndrome de hochement de tête à médiation du trijumeau a été posé. Le traitement chirurgical a été réalisé avec une approche supraorbitale à la branche maxillaire du nerf trijumeau au sortir du foramen rond, où une neurolyse interne (peignage des nerfs) a été effectuée sur les nerfs gauche et droit. Le comportement de hochements sévères de la tête s'est résorbé après la chirurgie. Le cheval a manifesté un frottement de la face du museau qui a commencé 96 heures après la chirurgie et s'est résorbé pendant une période de 12 jours à l'aide d'une thérapie aux corticostéroïdes et à la vitamine E. Le cheval est devenu apte au pâturage et les signes cliniques se sont résorbés en présence de la lumière du soleil, mais les mouvements verticaux répétitifs de la tête ont persisté avec une selle, ce qui a rendu le cheval peu agréable pour la monture.(Traduit par Isabelle Vallières).

Spinal Instability Neoplastic Score (SINS): Reliability Among Spine Fellows and Resident Physicians in Orthopedic Surgery and Neurosurgery.

STUDY DESIGN: Reliability analysis. OBJECTIVES: The Spinal Instability Neoplastic Score (SINS) was developed for assessing patients with spinal neoplasia. It identifies patients who may benefit from surgical consultation or intervention. It also acts as a prognostic tool for surgical decision making. Reliability of SINS has been established for spine surgeons, radiologists, and radiation oncologists, but not yet among spine surgery trainees. The purpose of our study is to determine the reliability of SINS among spine residents and fellows, and its role as an educational tool. METHODS: Twenty-three residents and 2 spine fellows independently scored 30 de-identified spine tumor cases on 2 occasions, at least 6 weeks apart. Intraclass correlation coefficient (ICC) measured interobserver and intraobserver agreement for total SINS scores. Fleiss's kappa and Cohen's kappa analysis evaluated interobserver and intraobserver agreement of 6 component subscores (location, pain, bone lesion quality, spinal alignment, vertebral body collapse, and posterolateral involvement of spinal elements). RESULTS: Total SINS scores showed near perfect interobserver (0.990) and intraobserver (0.907) agreement. Fleiss's kappa statistics revealed near perfect agreement for location; substantial for pain; moderate for alignment, vertebral body collapse, and posterolateral involvement; and fair for bone quality (0.948, 0.739, 0.427, 0.550, 0.435, and 0.382). Cohen's kappa statistics revealed near perfect agreement for location and pain, substantial for alignment and vertebral body collapse, and moderate for bone quality and posterolateral involvement (0.954, 0.814, 0.610, 0.671, 0.576, and 0.561, respectively). CONCLUSIONS: The SINS is a reliable and valuable educational tool for spine fellows and residents learning to judge spinal instability.

Spinal dural arteriovenous fistula: a case series and review of imaging findings.

INTRODUCTION: Spinal dural arteriovenous fistulae (sdAVF) are rare lesions. Patients typically present with slowly progressive myelopathy that is often mistaken for degenerative cervical or lumbar stenosis. On spinal magnetic resonance imaging (MRI), multisegmental T2 hyperintensities along with associated flow voids are pathognomonic of sdAVF. However, diagnosis can be difficult. Definitive diagnosis and localization is achieved with complete spinal angiography. Treatment options include open surgical ligation, endovascular embolization or multimodality treatment. The purpose of this study is to present a series of cases to aid in the assessment, diagnosis and treatment of this unusual pathology. CASE PRESENTATION: We present 10 cases of sdAVF treated at our center over an 8-year period. Seventy percent of patients were male. The mean age of presentation was 62.6 years. The most common lesion was a dorsal dural AVF with single feeder. All patients underwent open surgical ligation, six having preoperative coil embolization of the radicular artery to allow for intraoperative localization of the fistula. Eight patients showed improvement following treatment as graded by the Nurick system. Two patients failed to improve. None of the patients worsened. One patient had a radiation burn from the spinal angiogram requiring secondary closure and one patient had a pseudomeningocele at the site of surgery that resolved. DISCUSSION: The successful treatment of sdAVF requires a detailed understanding of clinical presentation and imaging findings to allow for precise treatment. Owing to the rarity of the condition, clinicians must continue to share their experiences to advance our knowledge.

Giant Aneurysmal Bone Cyst of the Anterior Cranial Fossa and Paranasal Sinuses Presenting in Pregnancy: Case Report and Literature Review.

Background and Purpose Aneurysmal bone cysts (ABCs) rarely involve the cranium and have seldom been reported in pregnancy. Clinical Presentation We describe a case of a 28-year-old woman who presented at 37 weeks of gestation with 3 months of gradually worsening vision, 10 months of proptosis, and restricted ocular motility on the left. Brain imaging revealed a multicystic enhancing mass measuring 5.9 × 5.3 × 3.7 cm, centered on the cribriform plate on the left, extending into the anterior cranial fossa superiorly as well as the left nasal cavity, maxillary, sphenoid, and frontal sinuses. Her clinical course is described in detail; 3-month postoperative imaging demonstrated no residual mass. Conclusion A literature review revealed five previous cases of ABCs associated with pregnancy. We report a rare case of a giant ABC of fibrous dysplasia involving the paranasal sinuses and anterior cranial fossa. We postulate on the possible influence of pregnancy on the clinical course.

Migrating lumbar intrathecal catheter fragment associated with intracranial subarachnoid hemorrhage.

Intrathecal catheter placement into the lumbar cistern has varied indications, including drug delivery and CSF diversion. These Silastic catheters are elastic and durable; however, catheter-associated malfunctions are well reported in the literature. Fractured catheters are managed with some variability, but entirely intradural retained fragments are often managed conservatively with observation. The authors describe a case of a 70-year-old man with an implanted intrathecal morphine pump for failed back surgery syndrome who presented to an outside hospital with a history of headache, neck pain, nausea, and photophobia of 3 days' duration. He also described mild weakness and intermittent numbness of both legs. Unenhanced head CT demonstrated subarachnoid hemorrhage (SAH). A right C-5 hemilaminectomy was performed. This case is unique in that there was no indication that the lumbar intrathecal catheter had fractured prior to the patient's presentation with SAH. This case demonstrates that intrathecal catheter fragments are mobile and can precipitate intracranial morbidity. Extrication of known fragments is safe and should be attempted to prevent further neurosurgical morbidity.