Cauda equina syndrome secondary to lumbar disc herniation: Report of three cases

Cauda equina syndrome produced by the herniated lumbar intervertebral disc is a rare disorder that, if is undiagnosed and untreated in time, can have serious consequences for the patient and medico-legal implications for the surgeon. We report the clinical evolution of 3 patients with lumbar spinal stenosis who still present sphincterian and sexual dysfunctions many years after surgery, even if they were operated on immediately after admission. Reviewing the literature on this subject has allowed us to emphasize symptomes, pathophysiological mechanism and management regarding patients with lumbar spinal stenosis. The surgical decompression is indicated as soon as possible. The surgical decompression within 48 hours from onset allows maximum improvement of symptoms and absolves the surgeon of any medico-legal liability

Dumitru Bagdasar – rediscovered after 70 years

The authors present the case of a female patient with Sturge-Weber disease, who was operated in her childhood by Dr. Bagdasar and who is hospitalized in the Neurosurgery department after 72 years from operation, because of a craniocerebral trauma. The patient presents Dr. Bagdasar’s hand written documents which reveal the complex medical personality of the one who was the pioneer of modern neurosurgery in Romania

Operative treatment of lumbar spinal stenosis with interspinous implants: General overview

Interspinous process devices are an alternative treatment of symptomatic lumbar spinal stenosis (LSS) to conventional surgery. Are presented various kinds of interspinous devices: X-STOP, IN-SPACE, SUPERION, APERIUS, ceramic spacers. Pathophysiology of lumbar spinal stenosis is presented together with biomechanics of interspinous implants which reduce loads on the facet joints, reduce pressure in the posterior annulus, increase foraminal and spinal canal dimensions.Indications, contraindications and precautions related to interspinous device surgery are presented.The results of in vitro studies are confirmed in randomized clinical trials. The improvements are statistically and clinically important, compared to those reported for laminectomy

Cerebellar hemorrhage after resection of frontal meningioma: Case report

Introduction: Remote cerebellar hemorrhage is an infrequent complication, potentially harmful with an unclear etiologic mechanism. There may be incriminated multiple risk factors: arterial hypertension, use of antiplatelet medication (Aspenter), CSF aspiration or drainage associated with intracranial hypotension. Material and methods: We present a 69 year old woman with remote intracerebral hemorrhage that occurred after frontal parasagittal meningioma resection. Results: An inadequate oral hydration was responsible for decreased level of consciousness, cerebellar and parietal-occipital cortical-sub-cortical contra-lateral hemorrhages. Close monitoring of water balance and adequate hydration is related to clinical improvement and resolution of brain imaging. Conclusion: Retraction of the brain due to intracranial hypotension led to some small vessels rupture and development of remote cerebellar hemorrhage

Giant hyperostosis after sphenoid ridge en plaque meningioma removal

Meningioma is in most cases a benign tumor of the central nervous system with two growth patterns: en masse and en plaque. Hyperostosis is associated in 13 – 49 % of the cases with en plaque meningioma. We describe the case of a 47 years old woman with meningotelial sphenoid ridge meningioma which was totally removed. At the first admission she presented with no neurological deficits, seizures and a mild right exophthalmos. This had an indolent growth. After 10 years, the patient was readmitted for headache, blurred vision and right exophthalmos. Skull X-rays and brain MRI revealed an important thickening of the right superior orbit wall and sphenoid ridge. She underwent a new surgery. There was no intradural tumor found. Instead, bones of the superior and lateral right orbit walls were very hiperostotic. A hole of 3/2 cm in the right superior orbital wall was drilled and the orbital cavity was decompressed. In the postoperative period, the symptoms were remitted and the exophthalmos reduced. We discuss the causes and management of hyperostosis associated with meningiomas

Topical vancomycine and bacterial culture from intervertebral herniated disc prevent postoperative osteodiscitis

Osteodiscitis represents a serious complication of lumbar disc herniation operations. The treatment of osteodiscitis is controversial and expensive to society. It extends over a period of several months from diagnosis. Reducing postoperative osteodiscitis by using simple measures may limit patient's suffering and reduce costs. The purpose of this study is to evaluate the early diagnosis of bacterial infections of the intervertebral disc by isolating germs located in the herniated disc fragment and topical Vancomycine powder application, along with the conventional anti-infective therapy. Medical files of patients who were operated on for lumbar disc herniations during 01.01.2013 - 30.06.2014 were reviewed. The diagnosis of lumbar disc herniation was established based on the clinical evaluation, confirmed by MRI results. The surgical intervention was performed by mini-open approach: fenestration and foraminotomy completed with removal of the herniated disc fragment and disc remnants from the intervertebral space. A group of 162 patients (group A) received conventional therapy for prevention of post-operative infections with 2 doses of cephalosporin. In the second group of 137 patients (group B), after the removal of the herniated disc fragments, 1g of Vancomycine powder was topically applied and the disc fragments were bacteriologically analyzed. They received the conventional treatment of preventing post-operative infections with cephalosprin - 2 doses. The two groups of patients were similar in terms of demographic characteristics: age, sex, operative level. Out of the 162 patients of group A, one patient developed postoperative osteodiscitis and was treated for 3 months with antibiotics. Regarding patients in group B, in four cases Staphylococcus was isolated from the disc fragments. Postoperative treatment for these patients with prolonged antibiotic therapy over the standard period avoided the developement of the clinical picture of osteodiscitis. Postoperative osteodiscitis requires prolonged antibiotherapy. By using simple measures, like topical Vancomycine powder application and early isolation of germs from the herniated intervertebral disc, followed by the immediate establishment of appropriate antibiotic treatment, this serious complication is avoided

Microcystic meningioma mimicking an arachnoid cyst

Microcystic meningioma is a particular morphopathological form of benign meningiomas, with different imaging characteristics compared to other forms of meningiomas. It is presented the case of an 80 year old woman with repeated head injuries, initially operated for a right fronto-temporo-parietal pericerebral fluid collection. After four years, the patient returned with headache, confusional status, somnolence, symptoms wich appeared after a new head injury. Cerebral CT scan revealed a hypodense lesion in the right sylvian fissure of 5.7/3.5 cm, without perilesional edema, which was interpreted as an arachnoid cyst. Intraoperative, a soft, gelatin-fibrous tumor mass was identified, partially adherent to the dura mater and the underlying cortex, which was completely resected. The morphopathological diagnosis was microcystic meningioma. It is discussed the imaging aspect of the presented case compared to the literature data regarding the microcystic meningiomas and the relationship between head traumas and the occurrence of meningiomas

A retrospective comparison of laminectomy and unilateral fenestration with foraminotomy on outcome of patients with lumbar spinal stenosi

Background: Neural decompression for lumbar spinal stenosis (LSS) can be performed, besides conventional lumbar laminectomy, by many other surgical techniques.Objective: The goal of this study is to analyze the results of laminectomy versus unilateral fenestration and foraminotomy with bilateral neural decompression in LSS patients.Methods: A number of 58 patients with lumbar spinal stenosis were divided into two groups: group A (no.=22) consists of patients that underwent a laminectomy procedure and group B (no.=36) of cases where unilateral fenestration with foraminotomy was used. Outcome was assessed at 1, 6 and 12 months postoperatively. Two parameters were evaluated: level of pain with the VAS (Visual Analogue Scale) score and the ODI (Oswestry Disability Index) scale for functional improvement.Results: The level of pain was reduced in both patient groups. Cases in group A maintained higher levels of back pain in the first postoperative month versus group B. Improvement was faster for those operated by unilateral approach. At 6 months and 1 year follow-ups, VAS values were very similar. All patients presented functional recovery evaluated with the ODI scale, that showed continuous improvement at 6 months and 1 year.Conclusions: Bilateral decompression by unilateral approach is an efficient method that represents the first option of treatment for patients with lateral lumbar spinal stenosis with unilateral or predominantly unilateral symptoms. For patients with severe central stenosis, classic laminectomy remains the first surgical choice

Diagnostic challenge in a patient with primary bilateral Dumbbell-shaped lumbar non-Hodgkin’s lymphoma

Objective: Primary bilateral dumbbell-shaped lumbar non-Hodgkin lymphomas with epidural and extraspinal involvement, are rare occurrences. Patients presenting at advanced stages and rapid evolution towards neurological impairment lead to diagnostic dilemmas for which only immunohistochemistry can provide a correct, although delayed solution. Case report: We report the first case of a bilateral, dumbbell-shaped, lumbar lymphoma in a 65-year-old man with a medical history of chronic viral hepatitis type B and D under interferon treatment. The patient presented with back pain radiating down the right leg, with rapid progression to paraplegia and sphincter dysfunction. CT and MRI revealed a large dumbbell mass (approx. 5/5/10 cm) in the right paraspinal musculature, at the L4-L5 level, with intraspinal epidural extension. A similar mass of smaller size was described on the left side, almost mirroring the first lesion, the imagistic aspect suggesting a neural sheath tumor. Intraoperatively, in the right lumbar paraspinal musculature, a soft, yellowish region was discovered, the macroscopic appearance being rather suggestive for a diffuse infection. Clinical, imagistic and surgical findings were not conclusive, nor was the histological examination in light microscopy of the surgical specimen or of the bone marrow biopsy. Immunohistochemistry identified the presence of large B cells, leading to the diagnosis of B cell lymphoma. Although the patient was treated with systemic chemotherapy, his condition rapidly deteriorated and he died within 3 months. Conclusions: In the case of a lumbosacral, dumbbell shaped mass, developed both epidural and extraspinal, the differential diagnosis must include lymphoma. The histological examination, especially immunohistochemistry provided the final diagnosis. Delays in establishing a diagnosis, associated with a malignant evolution of lymphoma, diminish the chances of determining and applying a treatment strategy that could prolong survival