Undetected Dural Leaks Complicated by Accidental Drainage of Cerebrospinal Fluid (CSF) can Lead to Severe Neurological Deficits

Analysis of Vacuum-Assisted Closure-Assisted Antibiotic Irrigation in Treatment of Severe Neurosurgical Central Nervous System Infections

Objective: Severe neurosurgical central nervous system infections (sNCNSIs) are among the most serious complications of neurosurgical disease. Conventional methods have shown a poor prognosis. This study aims to analyze the clinical characteristics of vacuum-assisted closure (VAC) in sNCNSIs with the help of antibiotic irrigation treatment. Patients and Methods: A retrospective study was performed for patients diagnosed with sNCNSIs. A VAC device was placed on the incision after debridement and the surgical cavity was rinsed with antibiotic agents in the VAC group. Meanwhile the surgical cavity was drained after debridement in the control group. Medical data were reviewed and analyzed. Results: Twenty-eight patients met the inclusion criteria, including 18 cases in the VAC group and 10 cases in the control group. The basic medical data showed no differences. Bacteria was isolated from 24 (85.7%) patients. The cure rate was significantly higher in the VAC group (p < 0.05). The cure rate in patients with multi-drug-resistant (MDR) infections was significantly higher in patients treated with VAC therapy (p < 0.05). The prognosis evaluated by Glasgow Outcome Score (GOS) between the two groups showed significant difference (p < 0.05). No re-infection in the VAC group occurred in the follow-up period. Conclusions: It is suggested that VAC-assisted antibiotic irrigation is safe and effective for patients with severe NCNSIs and can improve the prognosis dramatically. The results can provide a new effective and reasonable therapeutic strategy for patients with sNCNSIs.

A Critical Update of the Classification of Chiari and Chiari-like Malformations

Chiari malformations are a group of craniovertebral junction anomalies characterized by the herniation of cerebellar tonsils below the foramen magnum, often accompanied by brainstem descent. The existing classification systems for Chiari malformations have expanded from the original four categories to nine, leading to debates about the need for a more descriptive and etiopathogenic terminology. This review aims to examine the various classification approaches employed and proposes a simplified scheme to differentiate between different types of tonsillar herniations. Furthermore, it explores the most appropriate terminology for acquired herniation of cerebellar tonsils and other secondary Chiari-like malformations. Recent advances in magnetic resonance imaging (MRI) have revealed a higher prevalence and incidence of Chiari malformation Type 1 (CM1) and identified similar cerebellar herniations in individuals unrelated to the classic phenotypes described by Chiari. As we reassess the existing classifications, it becomes crucial to establish a terminology that accurately reflects the diverse presentations and underlying causes of these conditions. This paper contributes to the ongoing discussion by offering insights into the evolving understanding of Chiari malformations and proposing a simplified classification and terminology system to enhance diagnosis and management.

Intracranial Hypotension Syndrome: The Importance of Neurointensive Care

Surgical procedures involving the spine can result in various complications, including vascular, nerve root and dura mater injury, surgical wound infection, and hematoma formation. Unintentional durotomy is a frequent complication of these procedures (up to 17%). Two clinical cases are reported in which the occurrence of epileptiform activity in the form of generalized tonic-clonic seizures after instrumentation of the dorsal and lumbar spine raised suspicion of cerebrospinal fluid (CSF) fistula. In both cases, the diagnostic suspicion and early approach allowed for the adoption of a timely medical and surgical plan, with the aim of reducing the volume of lost CSF as well as the potential neurological dysfunction resulting from this surgical complication.

A case report of seizure during emergence from general anesthesia after lumbar spinal surgery-common cases can develop potentially life-threatening adverse intracranial events

Background

Adverse intracranial events after spinal surgery were related with intracranial hypotension due to surgical injury of dura mater.

Case presentation

A 72-year-old woman received posterior lumbar interbody fusion under general anesthesia. Immediately after the patient was transitioned to the supine position and muscular relaxants were reversed, she developed generalized seizure. The seizure was immediately suppressed with propofol. Brain computed tomography was unremarkable. Although she returned to the surgical suite, an evident point of dural laceration was not found. The dura was covered with fibrin glue. Magnetic resonance imaging revealed subarachnoid hemorrhage (SAH) on postoperative day 1. By postoperative day 2, the seizure had resolved. The cause of her seizure was suspected to be SAH due to intracranial hypotension. Seizure was masked by ongoing anesthesia and muscle relaxation.

Conclusions

Although spinal surgeries are common procedure, we must carefully consider its related potentially life-threatening adverse events.