Late laminectomy in traumatic paraplegia

Long-term observation in cases of spinal injury with sub-arachnoid block, treated by laminectomy and removal of compressing elements, shows worthwhile results in a good percentage. Twenty-seven cases of fractures of the spine at the dorsolumbar and lumbar levels with conus and cauda equina injury were treated by laminectomy and decompression from 6 to 12 weeks after the injury, and have been followed for periods of 3-27 years. Surgical intervention was offered only in those cases in which myelography demonstrated a subarachnoid block. Most of the cases were operated on at 6-12 weeks after the injury. Displaced laminae, thickened ligamentum flavum, and arachnoidal adhesions were the common causes of compression. In six cases there was also an arachnoid cyst. Long-term follow-up showed improvement in bladder function in 14 of 27 patients, and in motor function in 8 of 27. In dorsolumbar and lumbar injuries in which there is a subarachnoid block, decompressive laminectomy is a worthwhile procedure

Giant invasive spinal schwannomas: definition and surgical management

Object: Confusion exists regarding the term giant spinal schwannoma. There are a variety of nerve sheath tumors that, because of their size and extent, justify the label "giant schwannoma." The authors propose a classification system for spinal schwannomas as a means to define these giant lesions. The classification is confined to tumors that are essentially intraspinal, with or without extraspinal components. Lesions that erode the vertebral bodies (VBs) and extend posteriorly and laterally into the myofascial planes are classified as giant "invasive" spinal schwannomas. Methods: The records of patients with giant invasive spinal schwannoma were analyzed. The radiological features, operative approaches, and intraoperative findings were noted. Ten patients with giant invasive tumors were surgically treated over the last 8 years. Six patients were male. Erosion of the posterior surface of the VBs was the diagnostic finding demonstrated on plain x-ray films. Magnetic resonance imaging delineated the extent of the tumors and helped in preoperative planning. Radical excision of the tumors in multiple stages was possible in eight of the 10 patients. Dural reconstruction was required in four patients. All patients required fusion, and an additional stabilization procedure was undertaken in three patients. Conclusions: The authors conclude that giant invasive schwannomas are uncommon lesions and propose a new classification system. Because of their locally "invasive" nature and extension in all directions, careful preoperative planning of the surgical approach is very important. Although radical excision is possible and promises good results, recurrences may occur and multiple surgical procedures may be required

Glioblastoma multiforme occurring in a child with acute lymphoblastic leukemia

A three and a half year old boy was diagnosed to have acute lymphoblastic leukemia in September 2002 and was treated with induction chemotherapy. He also received prophylactic cranial irradiation (12 Gy) and intrathecal methotrexate. In November 2005, at the age of 7 years, he developed right focal seizures and was diagnosed to have a glioblastoma in the left parietooccipital region while the leukemia was in remission. The possibilities are the glioma may have been radiation- and / or chemotherapy-induced

Invasive rhino-cerebral fungal granuloma

Background: Increased incidence of fungal infection has been reported globally in the recent years. Fungal infection of the central nervous system remains one of the most difficult diseases to treat and requires multi-modality intensive therapeutic strategies. Materials and Methods: Retrospective analysis of case records of patients with confirmed skull base fungal granuloma treated at a tertiary hospital between 1988-2008. An attempt was made to stage the extent of skull base fungal granuloma based on neuroimaging, operative findings and course of the disease on serial follow-up. Results: Thirty-three patients with skull base fungal granuloma were treated surgically during the study period. The mean age at presentation was 33.2 years and diabetes was a major predisposing factor. Eight patients expired in the first two months following surgical intervention due to flare-up of the disease. Eighteen patients who underwent grossly total excision had a mean progression-free survival (PFS) of 43 months and seven patients with subtotal excision had a mean PFS of 23 months. Better survival probability was noted in those patients who underwent total excision at surgery and received complete course of amphotericin. Conclusion: Total surgical excision with complete course of antimycotic drug therapy increases PFS. A better antimycotic drug with less toxicity and high efficacy with fungicidal property can make a difference in the outcomes of the disease

Suboccipital segment of the vertebral artery: A cadaveric study

Objective: To study the course, relationships, branches and possible anomalies of the vertebral artery in the suboccipital region in adult Indian cadavers. Materials and Methods: Twenty-one suboccipital segment vertebral artery specimens from embalmed, Indian adult cadavers were dissected and studied. Dissection was performed using microsurgical instruments and was carried out from the skin up to the vertebral artery in layers. The course, relationships and the branches of the vertebral artery were studied and measurements were taken using Vernier calipers. The readings obtained were corroborated with the measurements derived from the digital images using a computer. Observations: All the vertebral arteries had a tortuous course and were covered with rich venous plexuses. None of the specimens had an anomalous course. The artery was divided into a vertical segment (Vv) between C2 and C1 vertebra and a horizontal segment (Vh) from the C1 transverse foramina to its dural entry. The mean diameter of the artery was 4.8mm. The shortest distance of Vv segment from the dural tube was 16.1mm, and the distance from the C2 ganglion was 7.2mm. The average length of the Vv segment was 15mm and the average length of the Vh segment was 35.6mm. The average of the shortest distance between the vertebral artery and the midline was 13.4mm. Conclusion: The vertebral artery has a tortuous course and is prone to accidental iatrogenic injury, which can result in devastating neurological sequelae depending on contralateral vertebral artery flow. A thorough anatomical knowledge of this segment is essential for the surgeon who intends to operate in this area

Primary interhemispheric subdural empyemas: A report of three cases and review of literature

Background: Interhemispheric subdural empyema is an uncommon condition and is considered neurosurgical emergency. These are generally seen following neglected otorhinological infection, but may be posttraumatic or iatrogenic in origin. The source of infection can be frequently found, but in few cases no source of infection can be identified, called idiopathic empyemas. These idiopathic interhemispheric subdural empyemas are even rare. They can present with a rapid progression of symptoms and can carry poor prognosis. Early intervention with craniotomy and appropriate antibiotics can improve the condition of these patients. Materials and Methods: We present three cases of idiopathic interhemispheric empyemas who underwent emergency craniotomy and evacuation followed by antibiotics for 6 weeks. Results: All the patients had excellent recovery on mean follow-up of 10 years. Conclusion: Early diagnosis and treatment of interhemisheric subdural empyema can lead to excellent recovery and outcome

Cystic meningiomas

Background: Meningiomas are generally solid tumors and are easily diagnosed by CT scans and MRI scans. Rarely are these tumors associated with cysts that can cause a confusion in the pre- and intraoperative diagnosis. Cysts associated with meningiomas may be intratumoral or peritumoral. Methods: The authors conducted a retrospective study of the seventeen meningiomas, out of a total number of 232, which were associated with cysts. The cysts were classified based on their relationship to the tumor. The patients' sex, age group, location of the tumor, and pathological type of tumor were also analyzed. Results: The 17 cases of cystic meningioma formed 7.3% of the meningiomas seen between 1984 and 1993. Eleven of these were intratumoral and 6 peritumoral. One case had both intra- and peritumoral cysts. The tumors were found mostly in the fourth and fifth decades of life. Histologically, all the peritumoral cysts except one were associated with meningotheliomatous meningiomas. Tumors with peritumoral cysts were more common in males. Intratumoral cysts, more common in females, were angioblastic or meningotheliomatous on histopathology. Only one case was an anaplastic meningioma. Conclusion: Cysts associated with meningiomas, although uncommon, are certainly not rare. The peritumoral and the intratumoral cysts form distinct subtypes needing separate consideration. Cystic meningiomas are only rarely malignant