Claudio Piqueras

Lumbar canal stenosis: a cause of late neurological deterioration in patients with spina bifida

BACKGROUND Patients diagnosed with spina bifida may show late deterioration. This worsening in their clinical symptoms has been attributed to a multiplicity of causes such as secondary tethering of the spinal cord, Chiari II anomaly, hydromyelia, diastematomyelia, arachnoid cysts, and dermoid tumors. METHODS We searched the clinical records of patients diagnosed with spina bifida who were treated at our hospital for a period of 25 years for the purpose of ascertaining the number and etiology of cases of late neurological deterioration. RESULTS Six of 144 patients with open spina bifida presented with late neurological deterioration. In one of these cases and in another patient with occult spina bifida the most relevant factor noted during surgery was the presence of marked lumbar canal stenosis. CONCLUSION We suggest that certain cases of late clinical worsening in spina bifida patients are because of lumbar canal stenosis and that this condition should be added to the list of causes that may produce delayed neurological deterioration in patients with spinal dysraphism.

Evaluation and management of small dural tears in primary lumbar spinal decompression and discectomy surgery

Incidental dural tear is one of the most common intraoperative complications in lumbar spine surgery. Yet, its technical management for the prevention of CSF leak is controversial. The technique of managing dural tears depends on the location of the dural tears as well on the length and anatomical characteristics of the dural tear. We propose an anatomical classification for small (less than one cm) dural tears and report on the outcome of managing these dural tears types using different technique for different type. 62 patients underwent spinal dural repair after microdiscectomy or lumbar spinal decompression. Group 1 consisted of 20 patients, with Type I or mild dural tear who had tissue-glue coated collagen sponge or fibrin glue application. Group 2 comprised 21 patients with Type II or moderate dural tear who had both tissue-glue coated collagen sponge and fibrin glue application. Group 3 comprised 21 patients with Type III or severe dural tear who had polypropylene suture and tissue-glue coated collagen sponge and/or fibrin glue application. Evident postoperative CSF leak was used to determine the patients postoperative result. Postoperative CSF leak was not evident during a minimum 1 year follow up in group 1. Internal CSF leak was evident in group 2 (n = 3) and group 3 (n = 3) during same follow up. Three patients underwent re-do spinal surgery for CSF leak repair. We recommend different management technique depending on the type of tear. For type I, we recommend the use of tissue-glue coated collagen sponge or fibrin glue application, without dural suturing.

Hydrocephalus Associated With Arachnoid Cysts

Abstract Arachnoid cysts (ACs) produce symptoms (1) directly by compression of the adjacent brain, (2) indirectly by blockage of cerebrospinal fluid (CSF) pathways, or (3) by bleeding. Absolute indications for treatment of ACS include brain compression, increased intracranial pressure, and hydrocephalus. But not always can the presence of an AC be regarded as responsible for the patients’ presenting symptoms. Much controversy exists about the need for surgical treatment of these cysts. In addition, many ACs merely represent incidental findings. Basically, the current options for the treatment of intracranial ACs include cyst fenestration (by endoscopic or open surgery) and cyst shunting. Cyst fenestration is directed towards relieving the cyst pressure by establishing a communication from the cyst to the cisterns or subarachnoid spaces. This option may also include the partial or total excision of the cyst’s walls. Cyst shunting consists of a draining system that vents the cyst fluid to an intra- or extracranial compartment by using some sort of CSF derivation. In spite of the reported diversity of surgical options, the most important issue regarding AC management still arises from the indications on which and when ACs should be treated. Hydrocephalus may as well occur in association with ACs constituting a sound indication for surgery. Hydrocephalus usually originates from obstruction of the CSF pathways and is considered as being of obstructive type. However, some authors propose a common origin for both hydrocephalus and AC formation attributing this association to impairment in CSF absorption, in which case the hydrocephalus is regarded as communicating. This distinction is not only of academic interest but it also has practical consequences at the time of choosing the most appropriate treatment. The occurrence of hydrocephalus is closely related with the location and size of the cysts. Broadly speaking, hydrocephalus mainly occurs in midline and posterior fossa cysts, while it is infrequent in sylvian and convexity lesions. The introduction of endoscopic techniques has lead to a dramatic change in classic treatments as open fenestration and cystoperitoneal shunting. At present, many instances with hydrocephalus and ACs can be managed exclusively with neuroendoscopic procedures in a simultaneous way although some instances will still require CSF shunting. The ideal treatment seems to consist of performing the modality that offers a high success rate using a single procedure that simultaneously addresses the treatment of both the hydrocephalus and the AC.

Delayed Spinal Cord Herniation After a Swordfish Attack

To the Editor: Swordfish attacks in humans are extremely unusual occurrences, and those with lesions located at the spinal canal are even rarer. This case illustrates the treatment potential and the case for surgical repair in a patient with a delayed spinal cord herniation after swordfish bill injury. A 39-year-old professional scuba diver presented in 2000 with a penetrating wound in the left chest cavity by the attack of a swordfish.His initial clinical evaluation disclosed penetrating injury below the left clavicle (Figure A), massive hemopneumothorax, and fracture of the vertebral body of D5. It required urgent surgery by thoracotomy with segmentectomy of the left upper lobe and foreign body removal nestled in D5 vertebra. He required later reconstruction of the latissimus dorsi and serratus muscles in 2001 (Figure B). After recovery, the patient resumed an active life with no residual discomfort limiting for his physical and work activities. In 2012, after intense physical exercise, he had a first episode of axial pain through the cervicodorsolumbar area with high stiffness and disabling muscle spasms, requiring hospitalization. After partial control of pain and complementary tests, including dorsal and lumbarmagnetic resonance imaging (MRI) and computed tomographic (CT) scan, he was dischargedwithadiagnosis of acute exacerbationof chronicmechanical back pain, old fracture at the D5 vertebra (Figure C), and L5-S1 disc protrusion. In this episode, the patient develops a sensory deficit on the left side of the body, including the left lower limb, with a sensitive level up to left nipple, which has remained since. He had normal strength in all 4 limbs. A repeated dorsal MRI with fine cuts revealed an anterior spinal cord herniation (Figure D-E) at the fracture site. He underwent direct repair of the herniation through a left D4-D5 costotrasversectomy, without consequences. His postoperative neurological examination revealed no changes and some pain relief. This case illustrates the potential delayed outcome after penetrating thoracic injuries, with indirect involvement of the spinal canal. The unusual occurrence of a swordfish attack, with a dorsal vertebra fracture and deferred spinal dural defect, made this case possible.

The human body through the El Greco’s eyes

Domenikos Theotokópoulus was born in Candia (1541, exact date unknown), Crete, which in that epoch belonged to the Republic of Venice. He is best known by the nickname of El Greco (the Greek) in reference to his birthplace. In Greece, he was educated in the post-Byzantine art and at the age of 26 years he traveled in Venice and then in Rome where he received influences from Mannerism and Renaissance styles. Looking for fortune, he moved to Madrid and then to Toledo (Spain) in 1577. In that time, Toledo that counted with more than 60,000 inhabitants was one of the largest cities in Europe. In the 1570s, the Monastery of El Escorial was being built and apparently there existed a lack of artists and painters to decorate the palace. El Greco initially made several paintings for Santo Domingo el Antiguo church in Toledo, probably protected by his close friend Luis de Castilla, dean of Toledo’s Cathedral. Subsequently, he tried to obtain the favor of King Philip II of Spain, but two of his works (Allegory of the Holy League and Martyrdom of Saint Maurice) were not completely approved by the king and he did not receive further royal commissions. Accordingly, he installed his workshop definitively in Toledo where he worked and lived until his death (7 April 1614).