Ali Akhaddar

Focal Intracranial Infections Due to Actinomyces Species in Immunocompetent Patients: Diagnostic and Therapeutic Challenges

OBJECTIVE Actinomyces spp. are often underestimated as causes of central nervous system infection because they are not looked for routinely and are difficult to detect. We try to determine the optimal management of these problematic intracranial infectious diseases in neurosurgical practice. METHODS Five cases of intracranial suppurations due to Actinomyces spp. treated between December 2007 and February 2009 are reported. The relevant clinicobacteriologic features and treatment outcomes are analyzed. RESULTS There were two brain abscesses, two subdural empyemas, and one frontal sinus pyomucocele with intracranial extension. Among them, three cases were previously operated and two patients were previously treated for otorhinolaryngeal infection. All cases were immunocompetent. In addition to Actinomyces sp., three patients had coinfectious bacteria (Pseudomonas aeruginosa, Staphylococcus warneri, and Escherichia coli). Complete resolution of the infection was achieved by means of aggressive surgical treatment and relatively short course of antibiotic therapy with a full recovery. CONCLUSION Actinomycotic focal cerebral infections may occur with greater frequency than previously recognized. Polymicrobial bacteria may be seen. This rare anaerobic organism should be considered in patients with a history of head trauma, previous surgery, or otorhinolaryngeal infection who present with a long duration of neurologic symptoms with or without an accompanying fever. Patients may be candidates for surgical debridement with relative shorter term of antibiotic therapy (ciprofloxacin).

Posterior ring apophysis separation combined with lumbar disc herniation in adults: a 10-year experience in the surgical management of 87 cases

OBJECT The association of posterior ring apophysis separation (PRAS) with lumbar disc herniation (LDH) is uncommon and represents a true subgroup of disc herniation mainly seen in the adolescent population. The objective of this study was to describe a decade of experience in the care of adult patients with PRAS with LDH, giving particular attention to its diagnosis, surgical treatment, and outcome. METHODS This retrospective study focuses on a case series of adult patients with PRAS associated with LDH who underwent surgery for lumbar disc disease in the authors neurosurgical department between 1999 and 2008. Posterior ring apophysis separation was diagnosed in 87 (5.35%) of 1625 patients surgically treated for LDH; these patients made up the PRAS group. During a 6-month period in 2005, LDH without PRAS was diagnosed in 89 consecutive patients at the same facility; these patients constituted the control group. Presenting symptoms, physical examination findings, and preoperative imaging results were obtained from medical records. Immediate operative results were assessed, as were complications, long-term outcome, and the need for repeat surgery. RESULTS This study is the first to document the distinguishing features between adult patients with and those without PRAS. The difference in average age was statistically significant (p < 0.001) between the study group (36.22 years) and the control group (44.30 years), as was the incidence of male patients (86.20% vs 71.91%, p = 0.020), incidence of military patients (74.71% vs 57.30%, p = 0.015), average duration of symptoms (16.13 vs 8.4 months, p = 0.016), and incidence of reactive scoliosis (19.54% vs 4.49%, p = 0.002). The most common anatomical location of disc herniation in the PRAS group was L5-S1 (51.72%) versus L4-L5 (53.93%) in the control group (p = 0.017). In terms of previous injury, motor deficits, back and/or leg pain, lateral or central location of LDH, mean anteroposterior diameter of disc herniation, hard or soft discs, and surgical complications, there was no statistical difference between the 2 patient groups. Similarly, there was no difference in recurrence rates and clinical outcomes between the patients with or without PRAS. CONCLUSIONS Posterior ring apophysis separation with LDH is probably more common in adults than is generally recognized. It must be suspected when young male patients with persistent sciatic scoliosis and no history of injury show signs of calcified LDH. Computed tomography scanning with sagittal reconstructions is the procedure of choice for diagnosing. The L5-S1 intervertebral disc level is most commonly affected, especially the superior endplate of S-1. This condition needs more extensive surgical exposure and resection to relieve the nerve impingement. The occurrence of an apophyseal lesion was not associated with recurrent disc herniation or a fair outcome.

Factors Influencing the Prognosis in Intracranial Dural Arteriovenous Fistulas with Perimedullary Drainage

OBJECTIVE Intracranial dural arteriovenous fistulas with perimedullary venous drainage (IDAVFPD) are classified as type V dural arteriovenous fistulas. Publications are limited to single case reports and small case series. We conducted a systematic review of the literature for patients with IDAVFPD. The aim of this study is to identify the predictive factors of poor prognosis in patients with IDAVFPD. METHODS We present the case of a 48-year-old man who underwent surgical interruption of IDAVFPD. A complete MEDLINE search was then undertaken for all articles reporting outcomes data for IDAVFPD. According to the results we have divided the patient population into two groups: I, those patients who showed improvement after treatment, and II: those patients who did not show improvement. We conducted a comparative statistical analysis of the epidemiologic, clinical, radiologic, and therapeutic parameters between the two groups. RESULTS A total of 37 articles comprising with 58 cases were included for analysis with an average follow-up of 12 months. There were 36 patients in group I and 22 in group II. The average age was 57.8 years in group I and 54.3 years in group II (P=0.32). Onset of symptoms was acute or subacute in 57% of patients in group I, and in 50% of patients in group II (P=0.62). Bulbar signs were present in 28% of cases in group I and in 36% of cases in group II (P=0.49). Hyperintensity of the brainstem on T2-weighted sequence magnetic resonance imaging was more common in patients in group II (78%) compared with patients in group I (45%) (P=0.012). Patients who underwent surgical procedure have shown good outcomes compared to patients treated with endovascular approach (P=0.039). CONCLUSIONS The poor outcomes were correlated to the presence of brainstem signal abnormalities on magnetic resonance imaging, whereas the prognosis does not depend on age, sex, clinical presentation, or anatomic characteristics of the fistula.

Radicular interdural lumbar disc herniation

Intraradicular lumbar disc herniation is a rare complication of disc disease that is generally diagnosed only during surgery. The mechanism for herniated disc penetration into the intradural space is not known with certainty, but adhesion between the radicular dura and the posterior longitudinal ligament was suggested as the most important condition. The authors report the first case of an intraradicular lumbar disc herniation without subdural penetration; the disc hernia was lodged between the two radicular dura layers. The patient, a 34-year-old soldier, was admitted with a 12-month history of low back pain and episodic left sciatica. Neurologic examination showed a positive straight leg raising test on the left side without sensory, motor or sphincter disturbances. Spinal CT scan and MRI exploration revealed a left posterolateral osteophyte formation at the L5–S1 level with an irregular large disc herniation, which migrated superiorly. An intradural extension was suspected. A left L5 hemilaminectomy and S1 foraminotomy were performed. The exploration revealed a large fragment of disc material located between the inner and outer layers of the left S1 radicular dura. The mass was extirpated without cerebrospinal fluid outflow. The postoperative course was uneventful. Radicular interdural lumbar disc herniation should be suspected when a swollen, hard and immobile nerve root is present intraoperatively.

Multiple isolated thoracic spinous process fractures (Clay-Shoveler’s fracture)

Clay-Shoveler’s fracture is an isolated spinous process fracture typically observed in the lower cervical or upper thoracic spine [1]. Multiple involvements are rare [1–4]. A 40-year-old car driver was involved in a road traffic accident with the seat belt buckled up. Clinical examination revealed an extensive tenderness on the skin over the posterior thoracic spine without neurological deficits. Computed tomography scanning of the cervicothoracic spine showed multiple thoracic spinous process fractures

Treatment of postoperative cerebellar mutism with fluoxetine

Dear Editor: This 13-year-old boy presented with a 4-month history of progressive headaches, vertigo, and blurred vision. At the initial presentation, he showed minor cerebellar ataxia with bilateral papillary edema. There were no further neurological deficits. The cranial MRI scan revealed a vermian fourth ventricular space-occupying lesion consistent with a medulloblastoma causing obstructive hydrocephalus. He had a right ventriculoperitoneal shunt with a medium-pressure valve inserted. The postoperative course was uneventful. One month later, a suboccipital median craniectomy approach was performed (in prone position) to remove the tumor. The histological examination revealed a medulloblastoma. The patient was asymptomatic for the first 2 days. However, on the third postoperative day, he developed significant reduced spontaneous speech and voluntary activity, concentration deficits, and drooling. These symptoms were in agreement with the diagnosis of cerebellar mutism. Laboratory examination revealed no abnormalities related to these symptoms. The postoperative CT scan demonstrated some edema without residual tumor, infarction, or bleeding in the primary site. Despite administration of corticosteroids with speech therapy, the symptoms worsened gradually. On the third postoperative week, the patient was started on 20 mg of fluoxetine at bedtime (for 9 weeks). Three to 4 days later, the patient’s mutism slowly resolved and disappeared completely about 4 weeks after starting fluoxetine, although some ataxia persisted in a mild form. There is no specific treatment that facilitated recovery from cerebellar mutism, although speech therapy, corticosteroids, and dopamine agonist bromocriptine and zolpidem are sporadically reported in the literature [1, 2, 5, 6]. On the other hand, fluoxetine is an antidepressant of the selective serotonin reuptake inhibitor class that is approved for the treatment of major depression (including pediatric depression), obsessivecompulsive disorder (in both adult and pediatric populations), bulimia nervosa, and panic disorder [7]. Since 1994, there have been a number of favorable reports on the use of fluoxetine in akinetic mutism [3, 4]. But to our knowledge, this drug has never been used on postoperative cerebellar mutism. The administration of fluoxetine in our patient coincided with improvement in symptoms, after a period of worsening before administration of this drug. The mechanism by which fluoxetine might ameliorate speech inhibition is unknown. Our children had no evidence of depressive disorders. So, as suggested by Dummit et al., the positive treatment effects cannot be attributed to an antidepressant effect of fluoxetine [4]. On the basis of our case report, we suggest that fluoxetine therapy may be efficacious in patients who manifest mutism after posterior fossa surgery.

Arachnoiditis ossificans of the cauda equina

Abstract A case of post-traumatic arachnoiditis ossificans of the cauda equina is reported. The lesion is a rare pathological entity usually confined to the thoracic and high lumbar regions that can cause progressive spinal cord and cauda equine compression. The pathophysiology and therapeutic strategy of this rare entity are still controversial.

Bacteriological features of infectious spondylodiscitis at Mohammed V Military Teaching Hospital of Rabat.

To review the bacteriological features of infectious spondylodiscitis and provide recommendations for the initial therapy which remains empirical in our context. Retrospective study including patients diagnosed with spondylodiscitis over a period of 4 years (2006-2009) at the Rabat Military Teaching Hospital. During the study period, we analysed 30 cases: the mean age was 49.9 years and 21 cases (70%) were male. The patients were predominantly hospitalized in neurosurgery department (15/30) followed by rheumatology department (10/30). The site of infection was lumbar in 21 cases (21/30), dorsal in 7 cases (7/30). 26 cultures were positive of which 19 (19/26) were monomicrobial. Tuberculosis (TB) was implicated in 10 cases (10/30) including 4 cases in association with common organisms (Propionibacterium acnes, Staphylococcus aureus, Staphylococcus epidermidis, Corynebacterium species). Brucella melitensis was isolated in 1 case. Infections caused by pyogenic bacteria were isolated in 15 cases of which 12 (12/15) revealed simple organisms including Gram-positive cocci in 9 cases (9/12) with 3 cases of S. aureus and Gram-negative bacilli in 3 cases (3/12) with 2 cases of P. aeruginosa. Blood cultures carried out for 16 patients were positive in 7 cases. The anatomopathologic exams carried out for 20 patients found in 6 cases epithelioid granulomata and giants cells with caseous necrosis in total concordance with TB culture. TB is the most frequent cause of spondylodiscitis in Morocco. Our study found the same frequency for non-specific and specific germs. Empirical treatment must take into account S. aureus and M. tuberculosis.

Acute postpartum paraplegia caused by spinal extradural capillary hemangioma

[1] Agosti JM, Goldie SJ. Introducing HPV vaccine in developing countries – key challenges and issues. N Engl J Med 2007;10;356(19):1908–10. [2] Munoz N, Bosch FX, de Sanjose S, Herrero R, Castellsague X, Shah KV, et al. Epidemiologic classification of human papillomavirus types associated with cervical cancer. N Engl J Med 2003;6;348(6):518–27. [3] Smith JS, Lindsay L, Hoots B, Keys J, Franceschi S, Winer R, et al. Human papillomavirus type distribution in invasive cervical cancer and high-grade cervical lesions: a meta-analysis update. Int J Cancer 2007;121(3):621–32. [4] Hammouda D, Munoz N, Herrero R, Arslan A, Bouhadef A, Oublil M, et al. Cervical carcinoma in Algiers, Algeria: human papillomavirus and lifestyle risk factors. Int J Cancer 2005;113(3):483–9. [5] Lalaoui K. El Mzibri M, Amrani M, Belabbas MA, Lazo PA. Human papillomavirus DNA in cervical lesions from Morocco and its implications for cancer control. Clin Microbiol Infect 2003;9(2):144–8. [6] Cuschieri KS, Cubie HA, Whitley MW, Seagar AL, Arends MJ, Moore C, et al. Multiple high risk HPV infections are common in cervical neoplasia and young women in a cervical screening population. J Clin Pathol 2004;57(1):68–72.

Solitary osteochondroma of the cervical spine presenting as recurrent torticollis

A 48-year-old man was referred to our unit for assessment of recurring episodes of painful torticollis. Family and past histories were unremarkable. There was no traumatic antecedent. During the previous three years he had experienced several episodes of torticollis and painful cervical movements without radiculopathy. His neurological examination was normal, except for a head tilt, decrease range of cervical motion and local tenderness on the right lateral side of the neck. Cervical spine radiographs showed a cervical scoliosis with right unilateral C5-C6 facet joint hypertrophy (A). Cervical computed tomography-scan and magnetic resonance imaging demonstrated a small bone regular tumor in the right C6 articular process and important amyotrophia of the neck musculature on the right side without nerve root or spinal cord compression (B and C). A posterior cervical approach was performed and the mass was completely removed without facet joint sacrifice. At surgery, the tumor appeared well-circumscribed, firm, and calcified with a cartilaginous-cap like appearance (D). Histological features were consistent with benign osteochodroma. The patient was discharged home pain free and referred for physiotherapy care with a good outcome. Osteochondroma is the most common benign tumor of bone (especially long bones), but the spine is rarely involved and usually indicates a hereditary cause such as osteochondromatosis (hereditary multiple exostosis). As seen in our case, this lesion is slow growing, and therefore significant spinal deformation can occur before the symptoms are recognized.