Management of Pregnancy- and Lactation-Related Osteoporosis: Case Series

AIM

Pregnancy- and lactation-related osteoporosis (PLRO) is a rare transient osteoporosis causing severe low back pain and morbidity in the last trimester of pregnancy and in the postpartum period. The etiology of PLRO is still unclear. We aimed to share our experience regarding management and follow-up of patients with PLRO who were effectively treated.

MATERIAL AND METHODS

In this case series, we presented 10 patients who were diagnosed with PLRO and treated from January 2010 to December 2020. VAS scale and laboratory findings were evaluated. Spinal and extremity magnetic resonance imaging (MRI) was obtained for patients with spinal and extremity pains. Dual energy X-ray absorptiometry was used for the measurement of bone mineral density. Values assessed on dual energy X-ray absorptiometry were L1-L4 T score, L2-L4 T score and femoral neck T score.

RESULTS

In the first-month follow-ups, all patients had meaningful pain relief and symptom resolution. The mean duration of pain control during the treatment period was 2.4 months. Two patients who continued breastfeeding were also the patients whose pain control was achieved at the latest. One patient required vertebroplasty surgery.

CONCLUSION

Patients with PLRO should be promptly treated and followed-up. Discontinuation of breastfeeding will provide rapid advantage and should be the first step of the management. Early diagnosis and treatment of Calcium and Vitamin D with conservative procedures with spinal braces are very important for the treatment of PLRO patients. Additionally, bisphosphonates or teriparatide can improved the bone mineral density in patients with PLRO.

Effects of Parenteral Fish-Oil Emulsion (Omegaven) on Cutaneous Wound Healing in Rats Treated With Dexamethasone

BACKGROUND

The aim was to assess wound healing when parenteral fish-oil emulsion is given to rats receiving dexamethasone.

METHODS

For 5 days after skin wounding, group S (control; n = 7) received saline 1 mL/kg intraperitoneal (IP); group D (n = 7), dexamethasone 0.2 mg/kg IP; and group DO (n = 9), dexamethasone 0.2 mg/kg IP plus 1 mL/kg Omegaven (Fresenius Kabi, Austria). Wound specimens were assessed for hydroxyproline level, wound depth, histology (epidermal/dermal regeneration, granulation tissue thickness, and angiogenesis), and expression of transforming growth factor-beta (TGF-beta) and platelet-derived growth factor-AA (PDGF-AA).

RESULTS

Compared with D and DO specimens, controls had higher hydroxyproline (p < .01), deeper wounds (p < .05), and better histologic scores (p < .01 angiogenesis; others p < .05). There were no significant differences between the group D and DO means for hydroxyproline level, wound depth, or histologic scores (p > .05 for all). Controls had higher TGF-beta expression scores than the other groups (p < .01 for both) and a higher PDGF-AA expression score than group DO (p < .01). Groups D and DO had statistically similar TGF-beta scores, but group D had a higher PDGF-AA score (2.71 +/- 0.75 vs 1.55 +/- 0.72, respectively; p < .05).

CONCLUSIONS

According to the parameters we studied, adding parenteral omega-3 and omega-6 fatty acids to the nutrition regimen of rats treated with dexamethasone does not seem to have adverse effects on wound healing, and effects on wound healing may not need to be considered when determining if these agents should be supplemented in nutrition support regimens.

Back pain after labour under epidural analgesia

In this case report we have discussed a parturient patient who had epidural analgesia during childbirth and then presented with back pain 50 days postpartum as well as the causes of postpartum back pain.

Effects of parenteral nutritional support with fish-oil emulsion on spinal cord recovery in rats with traumatic spinal cord injury

AIM

Aim of this study is to assess effects of parenteral nutritional support with fish-oil emulsion on spinal cord recovery in rats with traumatic spinal cord injury.

MATERIAL AND METHODS

For 5 days after SCI rats were received saline in group C and Omegaven in group O. Locomotor strengths (BBB scale)of animals were rated at Day 0,7,14,21,28, and 35. At Day 35 spinal cord sampling was evaluated immunohistochemically.

RESULTS

BBB scores were 0 in early period after SCI was inflicted in both groups. BBB scores were progressively increased after Day 7 in both groups (p < .005). BBB scores were significantly higher in group O when compared with control group after Day 7 in all times (p < .005). Neuronal injury (p < .002) and edema was much more in control group when compared with in group O (p < .005). Scores for white mater cavitation, demyelinization and vessel in growth were similar in both groups. VEGF expression in control group was higher (p=.019).

CONCLUSION

At the early period of SCI fish-oil emulsion treatment in rats, its anti-inflammatory effects leaded to decrease in edema and had positive effect at the prevention of neuronal injury. We believe that nutritional support with fish-oil emulsion in patients with SCI will result in patient's better clinical outcome and increase in quality of the patient's life.

Perineural cyst presenting like cubital tunnel syndrome

Perineural cysts are believed to be asymptomatic; however, they rarely cause symptoms related to nerve root compression. Cervical symptomatic perineural cysts are in fact exceedingly rare. There are no reported cervical perineural cysts in the literature that present like cubital tunnel syndrome. A patient with motor weakness of the abductor and adductor muscles of the fingers of the left hand and hypoesthesia in the hypothenar region of the left hand presented at our clinic. A neurological examination, and neuroradiological and electrophysiological evaluations supported the finding that the patient's clinical condition was caused by a perineural cyst located around the C8 neural root. The neurological symptoms of the patient markedly improved after medical treatment. We reported the first cervical perineural cyst as presenting like cubital tunnel syndrome patient in the literature. The visualization of perineural cyst may need extra magnetic resonance imaging (MRI) sections in order to view the nerve root through the neural foramen or extraforaminal area. These lesions are benign, and the appropriate treatment is curative.

Tumoral calcinosis and epidural lipomatosis of the lumbar spine

Lumbar spinal tumoral calcinosis and spinal epidural lipomatosis are rare conditions. We present a 70-year-old female patient with serology negative spondyloarthropathy who developed paresis due to tumoral calcinosis in the left facet joint between L5 and S1 levels and spinal epidural lipomatosis at L5 and S1 levels. Surgery was performed to excise the lesions en bloc. Neural decompression was provided. Neurological symptoms improved after surgery. Here, we report the first serology negative spondyloarthropathy case that had concomitant development of tumoral calcinosis and spinal epidural lipomatosis.

Pigmented villonodular synovitis of the spine: report of a lumbar case

Pigmented villonodular synovitis is a benign proliferative disease of the synovial structures. This disease is most commonly seen in the extremities, and spinal involvement is extremely rare. In the relevant literature, 53 cases have been reported. We present a 66-year-old female patient with a long history of back pain, which progressed and radiated to the left leg over a period of 2 months. The patient also had a mass in the lumbar region on the grounds of spinal degenerative changes. Following gross total excision, the diagnosis was established by histopathology. In this report, we present our experience and discuss our neuroradiological and clinical findings.

Outcomes for combined anterior and posterior surgical approaches for patients with multisegmental cervical spondylotic myelopathy

Corpectomy is widely used to treat cervical spondylotic myelopathy (CSM). However, when this technique alone is performed at 1 or 2 levels for a multisegmental involvement (3 or more vertebrae), the incidence of post-operative complications is high. The optimal treatment for multisegmental CSM is still debatable. The aim of this study was to assess clinical and radiological outcomes for patients with multisegmental CSM who underwent combined anterior and posterior (AP) surgical approaches. Forty adults (17 women and 23 men; age range, 41-76 y) treated at our center between 2004 and 2007 were reviewed retrospectively. Their neurological function was assessed at different times using the Nurick classification (Grades 0 [root symptoms only] to 5 [wheelchair- or bed-bound]). Patients' satisfaction with the surgery was evaluated using Odom's criteria (poor, fair, good, or excellent). Pre-operatively, 20% of patients were assessed as Nurick Grade 0, 60% as Grade 1, and 20% as Grade 2. At the 1-year follow-up, only 10% of patients were assessed as Grade 1. At 1 year after surgery, 85% of patients rated their satisfaction with the operation as "excellent" and 15% rated it as "good". These outcomes suggest that, when surgery is indicated and patients with multisegmental CSM are carefully selected, the combined AP approach yields symptom relief comparable to that of corpectomy alone and a lower incidence of post-operative complications.

Primary and secondary components of PM2.5 in Milan (Italy)

In sampling campaigns--carried out by means of a high-volume gravimetric sampler--performed between August 2002 and December 2003, 24-h PM2.5 samples have been collected at an urban background site in downtown Milan and analyzed for elemental and organic carbon, ionic species (i.e., chloride, nitrates, sulfates and ammonium) and some elemental species. Chemical speciation data are evaluated also in terms of primary and secondary components of fine particulate matter: in particular, the contribution of secondary organic aerosols (SOA) and of the primary contribution from traffic to observed PM2.5 concentration levels are evaluated by means of the EC tracer method.

Transmandibular approach for upper cervical pathologies: report of 2 cases and review of the literature

In routine surgical practice, anterior approaches are not often used to treat upper cervical pathologies. Such lesions can be difficult to access surgically. This article describes 2 cases in which the transmandibular approach was used to address anterior upper cervical pathology. One case was a chordoma invading the C2-C3 vertebrae and the other case was atlanto-axial instability. Neurological examination revealed myelopathy in both cases. Each patient had already undergone occipito-cervical fusion at a different center and, thus, had limited neck extension and mouth-opening ability. In the first case, the tumor was totally excised. In the second, the dens was removed. We believe that the transmandibular approach is the best option for patients with limited neck mobility and restricted mouth-opening ability.

The effects of inflammatory response associated with traumatic spinal cord injury in cutaneous wound healing and on expression of transforming growth factor-beta1 (TGF-beta1) and platelet-derived growth factor (PDGF)-A at the wound site in rats

At the cellular level, spinal cord injury (SCI) provokes an inflammatory response that generates substantial secondary damage within the cord, but also may contribute to its repair. The aim of this study was to investigate the effects of inflammatory response associated with SCI in cutaneous wound healing and on expression of transforming growth factor-beta1 (TGF-beta1) and platelet-derived growth factor (PDGF)-A at the wound site in rats. At the 14th day analysis, the mean TGF-beta1 score in trauma group (I) was significantly lower than that in control group (C) (2.60 +/- 0.90 vs. 3.64 +/- 0.37, respectively; p < 0.05). The mean score for PDGF-A expression in group I was similar to the corresponding value in group C (2.42 +/- 0.74 vs. 2.94 +/- 0.72, respectively). Compared to group C, group I had significantly lower mean scores for epidermal and dermal regeneration, but higher mean scores for granulation tissue thickness and similar scores for angiogenesis. The dermal layer contains diffuse deposition of collagen fibers that are not organised as in control rat skin, and intraepidermal and subepidermal vasocongestion is distinct. Based on the results on the parameters evaluated in the study, experimental SCI in rats results in delay in wound healing and low intensity of TGF-beta1 in the dorsal wound-tissue specimens.

Remifentanil and etomidate for laryngeal mask airway insertion

Etomidate does not depress the upper airway reflexes, making it difficult to insert a laryngeal mask airway (LMA) when using it for anaesthesia. This study investigated the effect of adding remifentanil to etomidate for LMA insertion. Fifty adult patients, undergoing cystoscopy, were randomized to two groups. The propofol-remifentanil group (n=25) received propofol anaesthesia induction (2.5 mg/kg) and a remifentanil bolus of 0.5 microg/kg, followed by a 2-min remifentanil infusion of 0.05 microg/kg per min. The etomidate-remifentanil group (n=25) received etomidate anaesthesia induction (0.3 mg/kg) and remifentanil as described. The LMA was inserted by a blinded anaesthetist who assessed a number of parameters. Only 13 LMAs were inserted at the first attempt in the etomidate-remifentanil group compared with 23 in the propofol-remifentanil group. Gagging, chest rigidity and myoclonus occurred significantly more frequently in the etomidate-remifentanil group. We conclude that the addition of remifentanil to etomidate anaesthesia induction does not improve LMA insertion.

Intraspinal gas

Intraspinal gas can be observed in a number of pathological settings including degenerative disc disease, infection, tumor or trauma, and in patients who have undergone therapeutic and diagnostic procedures. The air can be epidural, intradural or intradiscal. Intraspinal gas is usually asymptomatic. We report intraspinal gas in three patients, one with cervical, one with thoracic, and one with lumber disc disease and spondylolisthesis. The investigations were all completed at the the same medical center and CT and MRI were done in each case. The gas was in the epidural space in all three patients. These cases provide further evidence that intraspinal gas may persist without causing symptoms, and that resultant symptoms can disappear spontaneously. MRI is not reliable for diagnosing intraspinal gas; CT is recommended.

Foot drop: The first sign of an intracranial tumor?

Isolated foot drop due to a brain lesion is rare. A 48-year-old man complained of inability to dorsiflex the right foot. Right dorsiflexion had 0/5 muscle strength and there were no upper neuron findings on his neurological examination. Magnetic resonance imaging of the brain revealed a left parasagittal brain mass. The lesion was removed and muscle activity returned with 3/5 muscle strength 6 weeks after the operation. The parasagittal area is located at the foot of the homunculus. Therefore, in patients with foot drop, lesions of the parasagittal area should be considered.

Lumbar disc herniation in adolescence

Lumbar disc herniation very rarely occurs in adolescence. The aim of this study was to assess the radiological, clinical and surgical features and case outcomes for adolescents with lumbar disc herniation, and to compare with adult cases. The cases of 17 adolescents (7 girls and 10 boys, age range 13-17 years) who were surgically treated for lumbar disc herniation in our clinic between 1998 and 2003 were retrospectively reviewed. The mean follow-up time for these cases was 60 months. The collected histories revealed that 14 (82%) of the 17 cases involved trauma or intense sports activity. Low back pain was the most common complaint (15 cases, 88%). None of the 17 patients had major symptoms during follow-up, and most were engaged in intense sports or heavy work-related activities during this period. The main features of lumbar disc herniation in adolescents are different from those seen in adults. Careful assessment is vital to avoid misdiagnosis and prevent undesirable results from inappropriate surgery. When surgery is indicated and patients are carefully selected, the results of lumbar discectomy in adolescence can be satisfactory.

Cervical meningocele causing symptoms in adulthood: case report and review of the literature

Simple meningoceles are infrequent forms of dysraphism and are often benign. These lesions are usually associated with other congenital spinal anomalies, and are typically diagnosed in childhood. Most become symptomatic in childhood because of progressive spinal cord or nerve root tethering. This article describes the case of a 47-year-old man who presented with a sac in his posterior cervical region that had been leaking colorless fluid for 3 months. He was also having difficulty walking and complained of stiffness in his lower extremities. Cervical magnetic resonance imaging revealed a cystic mass in the region of the C4 to C5 laminae. Partial laminectomies were performed (lower portion C4 lamina, upper portion C5 lamina), the sac was totally excised, and tissue tethering the spinal cord were cut. There was no recurrence of symptoms in 12 months of follow-up. Although in cases where a cervical meningocele-myelomeningocele is detected at any time, early treatment is essential to eliminate the high risk of future neurological impairment. This is the first report of an untreated cervical meningocele manifesting symptoms in adulthood.

Superficial siderosis due to papillary glioneuronal tumor

Superficial siderosis of the central nervous system is a rare, progressive, irreversible and debilitating neurological disease characterized by the deposition of haemosiderin in the leptomeninges and the subpial layers of the brain and spinal cord. The main clinical findings are progressive bilateral sensorineural hearing loss, cerebellar ataxia and pyramidal tract signs. The present report describes a 49-year-old woman who presented with intermittent headache of 5 years duration. The pain had become more severe in the previous 6 months. Neurological examination revealed nothing abnormal. Computed tomography showed a cystic mass with apparent internal haemorrhage in the right frontal lobe and T(2)-weighted magnetic resonance imaging showed material of low signal intensity coating the entire surface of the brain. The mass was completely excised via craniotomy. A histopathological study identified the mass as a papillary glioneuronal tumour. The patient recovered well and is still neurologically normal 1 year later. This is the first documented case of superficial siderosis caused by this type of tumour.

Moyamoya disease and anesthesia

Moyamoya disease is a condition that results from bilateral stenosis or obstruction of the intracranial arteries at the base of the brain. Patients exhibit ischemic symptoms, and vascular reconstruction is the therapy of choice. Surgical treatment for Moyamoya disease is often complicated by cerebral ischemia, so the goal in perioperative management is to maintain the balance between oxygen supply and demand in the brain. This report presents three cases of Moyamoya disease in patients under 3 years of age, and discusses anesthesia management issues for pediatric patients with this condition.

Lumbar spinal angiolipoma: case report and review of the literature

Spinal angiolipomas are extremely rare benign tumors composed of mature lipomatous and angiomatous elements. Most are symptomatic due to progressive spinal cord or root compression. This article describes the case of a 60-year-old woman who presented with a 6-month history of low back pain radiating to her right leg. The pain was multisegmental. The condition had worsened with time. Lumbar magnetic resonance imaging revealed a dorsal epidural mass at L5 and erosion of the lamina of the L5 vertebra. Laminectomy was performed, and an extradural tumor was totally excised. Neuropathologic examination identified it as a lumbar spinal angiolipoma. There was no evidence of recurrence in follow-up 12 months later. This rare clinical entity must be considered in the differential diagnosis for any spinal epidural lesion.

Cerebellar hemorrhage after spinal surgery: case report and review of the literature

Recent reports indicate that cerebellar hemorrhage after spinal surgery is infrequent, but it is an important and preventable problem. This type of bleeding is thought to occur secondary to venous infarction, but the exact pathogenetic mechanisms are unknown. This report details the case of a 48-year-old woman who developed remote cerebellar hemorrhage after spinal surgery. The patient presented with a herniated lumbar disc, spinal stenosis, and spondylolisthesis, and underwent multiple-level laminectomy, discectomy, and transpedicular fixation. The dura mater was opened accidentally during the operation. There were no neurologic deficits in the early postoperative period; however, 12 h postsurgery the patient complained of headache. This became more severe, and developed progressive dysarthria and vomiting as well. Computed tomography demonstrated small sites of remote cerebellar hemorrhage in both cerebellar hemispheres. The patient was treated medically, and was discharged in good condition. At 6 months after surgery, she was neurologically normal. The case is discussed in relation to the ten previous cases of remote cerebellar hemorrhage documented in the literature. The only possible etiological factors identified in the reported case were opening of the dura and large-volume cerebrospinal fluid loss.

Spinal meningiomas: evaluation of 41 patients

AIM

Spinal meningiomas are relatively frequent intraspinal tumors. They constitute 25-46% of all primary spinal neoplasms.

METHODS

Forty-one patients with spinal meningiomas surgically treated between 1986 and 2001 are reviewed in this report. There were 32 females and 9 males, aged 16 to 73 years old. Tumor location was cervical in 7 cases and thoracic in 34 cases. All tumors were intradural. All of the patients were operated by laminectomy in prone position.

RESULTS

Total excision was achieved in 40 (98%) patients and subtotal excision in 1(2%). The majority of the tumors were meningothelial (42%) or psammomatous (25%). There was no surgical mortality. Four patients (10%) suffered from morbidity: One patient with CSF fistula, 1 deep venous thrombosis, 1 case with paraparesis and 1 wound infection was seen. Neither multiple meningiomas nor malign meningiomas were seen in our series.

CONCLUSIONS

Spinal meningiomas are benign tumors and should be excised totally. If the preoperative neurological status is not complicated, fairly good outcome can be achieved.

Surgical Treatment of Intramedullary Spinal Cord Ependymomas

OBJECTIVE

The aim of this study was to investigate whether the tumor parameters of spinal intramedullary ependymomas are significant predictors of clinical presentation and postsurgical outcome.

METHODS

The study involved 21 cases of intramedullary ependymoma that were operated on between 1988 and 2001. The patients were 13 males (62%) and 8 females (38%), with an age range of 9-70 years (median 38 years).

RESULTS

In most cases (13; 62%), preoperative neurologic examination revealed a sensorimotor deficit in at least one limb. Complete tumor removal was achieved in all cases. The patients with wider tumors had poorer preoperative neurologic condition and poorer neurologic outcome. Tumor length (equivalent to myelotomy length) was not correlated with preoperative neurologic status, but longer length was significantly associated with development of dysesthesia post surgery. In contrast to tumor length, tumor/cord ratio (ratio of the tumor width to the largest cord width at the tumor site) was identified as a significant predictor of preoperative neurologic status and outcome. Ratio values of >0.80 were correlated with poorer preoperative clinical status and poorer neurologic outcome. Neither extent of edema (determined from length [in millimeters] of hyperintensity on T2-weighted images) nor presence of a cyst in the tumor was significant relative to postoperative neurologic recovery in these cases.

CONCLUSIONS

This study demonstrated that the width of the tumor relative to the cord is the main predictor of neurologic presentation and postoperative status. The length of the tumor affects the postoperative dysesthesia development.

Biomechanical comparison of inside-outside screws, cables, and regular screws, using a sawbone model

Our aim was to conduct a biomechanical comparison of the pull-out strengths of inside-outside (I/O) screws, cables, and bone screws to determine whether I/O screws provide greater pull-out resistance than cables or bone screws, and their effectiveness with the screw diameter. There is no remarkable biomechanical experimental study comparing the I/O technique with conventional spinal techniques. The diameter of the screw heads were also biomechanically tested to determine the optimal size that can be used. In this study, 45 blocks of 50x50x5 mm of "sawbone" (synthetic bone, model 1137, Pacific Research Laboratories, Vashon, WA, USA) were used as bone substitutes. Fifteen sets of 14-mm inside-outside Dynalok screws and nuts, 15 wire cables, and 15 bone screws were inserted into a separate sawbone block. An MTS Bionx materials testing machine was used to measure the load to failure of each implant. The mean values and standard deviations of each group were calculated and Student's t-test was used for comparison. The load to failure of the inside-outside screws was significantly greater than that of the cables (p<0.0000004) and the regular bone screws (p<0.000002). The results also revealed that increasing the diameter of the head of the screw also increases the resistance against the pull-out strengths. Thus, using a larger screw in occipitocervical stabilization provides safe and stable fixation of the occipital bone to the cervical spine. This study also proved that sawbone is a useful and reliable alternative to allogenic fresh cadaveric bone grafts or animal bones for certain biomechanical testing.

The V2 segment of the vertebral artery and its branches

Object. The goal of this study was to demonstrate the origins, courses, anastomoses, and target tissues of the arterial branches that arise from the V2 segment of the vertebral artery.

Methods. Ten adult cadaveric necks (20 V2 segment specimens) were examined (magnification × 40) after injection of colored silicon. The branches at each cervical level were classified in a new system according to anatomical features and target tissues—anterior, posterior, medial, and lateral. Incidence with which each branch category was observed at each cervical level was calculated.

Anterior branches were observed at C-3 in all 20 V2 segment specimens. The incidence with which the posterior branch was present at C-4 was 45%, whereas the corresponding rates at segments superior and inferior were lower. The medial V2 segment branches were assessed in four subcategories. The anterior spinal artery was present at C-3 in all specimens, whereas the mean incidence at the C4–6 level was 46.7%. The posterior spinal artery was most frequently detected at C-3 (60%). The anterior radicular artery (RA) was present at C-5 in 50% of the specimens, whereas the posterior RA was detected at C-5 in only 35%. Lateral branches were most frequently detected at C-3.

Conclusions. The authors provide detailed anatomical information about the origins, courses, anastomoses, and target tissues of the vessels that arise from the V2 segment. This new classification allows for better understanding of the vasculature of the C3–6 region.

A retrospective review of cervical corpectomy: indications, complications and outcome

BACKGROUND

Cervical corpectomy is a common spinal surgery procedure used to decompress the spinal cord in numerous degenerative, traumatic and neoplastic conditions. The aim of this study was to investigate the indications, complications and outcomes in past cervical corpectomy cases at one centre.

METHOD

72 patients who underwent cervical corpectomy between February 1992 and June 2001 were retrospectively investigated.

FINDINGS

The indications for this operation were degenerative spondylitic disease (26 cases; 36.1%), trauma (18 cases; 25%), tumour (11 cases; 15.3%), infection (10 cases; 13.9%), and ossification of the posterior longitudinal ligament (7 cases; 9.7%). Thirty-seven patients (51.4%) underwent one-level corpectomy, and 35 (48.6%) underwent two-level corpectomy. Autografts were used in 13 cases (18.1%) and allografts were used in 59 cases (81.9%). Anterior plate-screw fixation was performed in all cases. There were 31 postoperative complications in 15 (20.8%) patients. Twelve of the complications were surgical, 5 were graft-related, 7 were plating-related, and 7 were medical. Solid bony fusion was achieved in 65 (92.9%) of the 70 surviving patients. The mean follow-up time was 23.4 months. An overall favourable outcome was achieved in 88% of cases.

CONCLUSION

The outcomes in this series indicate that cervical corpectomy is an effective method for treating traumatic lesions, degenerative disease, tumours and infectious processes involving the anterior and middle portions of the cervical spine.

Anterior Transcallosal Approach to the Colloid Cysts of the Third Ventricle: Case Series and Review of the Literature

OBJECTIVES

To evaluate the results of the anterior transcallosal approach to the colloid cysts of the third ventricle.

PATIENTS AND METHODS

A retrospective analysis of the patients operated on between 1986 and 2003 was carried out. There were 19 patients (10 female, 9 male) with a median age of 43. The main presenting symptom was headache. One of the patients presented with acromegaly due to a pituitary tumor. The size of the cysts ranged from 15 to 43 mm. An anterior transcallosal approach was used in all patients.

RESULTS

The cysts were excised totally in all cases. Postoperatively no recent memory loss has been detected in any patient. One patient with hemorrhagic papil stasis experienced temporary visual worsening. In one patient with hydrocephalus a ventriculoperitoneal shunt was needed. One patient with postoperative superior frontal gyrus venous infarction had a seizure. The follow-up period was from 1 month to 13 years (mean 5.2 years). To date, there has been no recurrence so far.

CONCLUSION

The anterior transcallosal approach is a safe method for the treatment of third ventricular colloid cysts.

Cauda equina syndrome after induction of spinal anesthesia

In this report the authors present a case of cauda equina syndrome that developed following induction of spinal anesthesia in a patient who had no apparent preexisting bleeding abnormality. An acute subdural hematoma caused the syndrome and was believed to have resulted from direct vascular trauma during administration of spinal anesthesia or from vascular trauma combined with thrombocytopenia in the postoperative period.

Cervical spinal cord intramedullary abscess. Case report

A case of progressive symptoms and signs of cervical spinal cord damage due to intramedullary abscess is reported. The literature is reviewed and the radiological features, particularly magnetic resonance image, are analyzed.

Cervical neural foraminal widening caused by the tortuous vertebral artery

A case of cervical neural foraminal widening due to tortuous vertebral artery is presented. This entity is rarely seen. Plain radiography, CT, 3-D CT angiography, MRI, and MRA findings of the case are presented and the importance of this vascular anomaly in the differential diagnosis of neural foraminal widening is discussed.

Diastematomyelia and spinal teratoma in an adult. Case report

Diastematomyelia, or split cord malformation, a complete or incomplete sagittal division of the neural axis into halves, is seen in association with many other congenital anomalies. Among these anomalies, intradural spinal teratoma is extremely rare. Diastematomyelia is a well-recognized although unusual clinical syndrome in children, but it is rarely reported in the adult. The authors describe a 42-year-old man who presented with pain and distal left-leg weakness as well as neurogenic claudication for 1 month. The patient underwent radiological examinations, and diastematomyelia and an intradural lumbar teratoma were diagnosed. He underwent surgery and was followed for 1 year. This is the fourth case of an adult who simultaneously presented with diastematomyelia and an intradural teratoma.

Treatment of the subarachnoid–pleural fistula

Subarachnoid–pleural fistula is a rare type of cerebrospinal fluid (CSF) fistula, and there are only several cases reported in the literature. The authors describe a 65-year-old male patient in whom a diagnosis of T7–8 disc herniation had been made. He underwent surgery via a right lateral extracavitary approach. Postoperatively he developed progressive respiratory distress and headache. A chest x-ray film revealed a pleural effusion, and computerized tomography (CT) myelography demonstrated a subarachnoidal-pleural fistula at the level at which the herniated disc had been removed. The patient had been managed via a CSF drainage system and a chest tube. He was discharged after relief of symptoms was attained. Subarachnoid–pleural fistulas can be secondary to traumatic injury and surgery, or they can be spontaneous. Patients present with rapidly filling pleural effusion and headache. A diagnosis can be established using CT myelography or myeloscintigraphy. Treatment is conservative, with the placement of a chest tube and insertion of a CSF drainage catheter, and surgical repair should be considered only if the conservative therapy fails.

Local anesthesia for extracorporeal shock wave lithotripsy: a double-blind, prospective, randomized study

OBJECTIVE

The efficacy of local anesthesia in decreasing intravenous analgesic requirements during extracorporeal shock wave lithotripsy with a second-generation lithotriptor was studied.

METHODS

Subcutaneous infiltration was performed before the procedure. Sixty-nine patients (ASA I-II) were randomly allocated into four groups. Lidocaine 1% plus epinephrine (5 microg/ml) were infiltrated subcutaneously in a group of patients with ureteral stones (group UL), and a group with renal stones (group RL). The same amount of saline was administered to a group of patients with ureteral stones (group UC), and a group with renal stones (group RC).

RESULTS

Patients with ureteral stones needed higher doses of intravenous analgesic. Neither patients with renal stones nor patients with ureteral stones administered local anesthetic required less intravenous analgesic than patients given placebo.

CONCLUSION

Local anesthesia did not decrease the requirement of intravenous doses of analgesics in patients treated with a second-generation lithotriptor (Dornier MPL 9000).