Naresh P. Patel

Spontaneous CSF leak treated with percutaneous CT-guided fibrin glue

Gladstone et al.1 advocate sealing CSF leaks with CT-guided, targeted fibrin glue injections in patients with spontaneous intracranial hypotension (SIH). We agree that the injection should be made at the site of the leak as a distant epidural blood patch may often give only temporary relief. In our SIH patients, we obtained permanent sealing of the leak in 13 of 16 cases in which the CSF loss at a spinal root level was approached either by direct surgery (three successful cases) or by targeted percutaneous …

Cervical kyphotic deformity correction using 360-degree reconstruction

Objective The authors report on their experience with cervical sagittal deformity correction using 360-degree reconstruction. Summary of Background Data A paucity of literature exists concerning 360-degree approaches for the correction of cervical kyphotic sagittal deformity in which the amount of deformity correction achieved, as well as the maintenance of deformity correction, is detailed. Methods The charts of all patients undergoing 360-degree cervical reconstruction for kyphotic sagittal plane deformity between 2000 and 2006 at Mayo Clinic Jacksonville and Mayo Clinic Scottsdale were retrospectively reviewed. Only patients with a minimum of 1-year follow-up were included in this study; 41 patients fit this criterion. The clinical data were further analyzed in this cohort to determine preoperative and postoperative sagittal angle, loss of correction, fusion rate, complications, and clinical status at last follow-up. Results Average follow-up was 19 months (range: 12 to 48 mo). The mean preoperative sagittal angle was 18 degrees of kyphosis (range: 3 to 58 degrees). The mean correction of sagittal angle was 22 degrees (range: 4 to 56 degrees), resulting in a postoperative mean sagittal angle of 4-degree lordosis. There was no loss of correction across the instrumented segments in any patient. Neurologic complications included 1 case of quadriparesis and 1 case of transient C8 radiculopathy. Conclusions The correction of cervical kyphotic sagittal plane deformity can be accomplished safely and effectively using a 360-degree approach. The incidence of major complications in this study was low. All patients could be corrected to a neutral or lordotic alignment. No loss of deformity correction was seen in any patient, and a 97.5% fusion rate was obtained.

Repair of esophageal perforation due to anterior cervical spine instrumentation

The complication of esophageal perforation after anterior cervical spine fusion for cervical spine disease is rare but potentially fatal. We describe two cases of esophageal perforation found by esophagoscopic visualization. In one patient, primary closure could not be achieved, and a submental island flap was used to repair the defect. In the second patient, primary closure was achieved and a pectoralis major flap was interposed between the closure and the residual instrumentation. Postoperatively, both patients had no evidence of persistent perforation and had resolution of preoperative symptoms. Laryngoscope, 2010

The role of corticosteroids in the management of chronic subdural hematomas: a critically appraised topic.

Background:Chronic subdural hematomas (CSDH) occur most commonly in the elderly population. When CSDH patients present with a moderate or severe neurologic deficit and are good surgical candidates, surgery is regarded as the ideal option. However, CSDH patients often have only mild neurologic deficits or are not optimal candidates for surgery. Corticosteroids are often used on these subgroups, but the benefit of this intervention is unknown. Optimal treatment for these patients is not well established. Objective:Critically evaluate the role of corticosteroids in the management of CSDH. Methods:The objective was addressed through the development of a structured critically appraised topic. This included a clinical scenario with a structured question, search strategy, critical appraisal, results, evidence summary, commentary, and bottom line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and clinical content experts in the fields of vascular neurology and neurosurgery. Results:No randomized controlled trials on the topic were discovered. A prospective cohort study was selected as the best currently available evidence. Conclusion:The role of corticosteroids in the management of CSDH is not well defined. Current evidence neither supports nor refutes the use of corticosteroids. A randomized controlled trial is warranted.

Progressive cervical myelopathy secondary to chronic ventriculoperitoneal CSF overshunting

CSF hypovolemia typically causes orthostatic headache with or without nonlocalizing symptoms such as neck pain, nausea, aural fullness, and dizziness.1 Focal complications are rare and are usually secondary to subdural hematoma. We report findings from a patient with progressive cervical myelopathy associated with cord distortion due to dural thickening and tortuous venous dilation. Chronic CSF hypotension caused by excessive ventriculoperitoneal shunting seemed to be the primary etiology. A 72-year-old woman presented for evaluation of an undiagnosed gait disorder. Twenty-seven years earlier she underwent right suboccipital craniectomy and ventriculoperitoneal shunt placement for a posterior fossa meningioma. There was no tumor recurrence or shunt malfunction. Four years earlier, she noted the insidious onset of right lower extremity spastic monoparesis. During the year prior to presentation, she developed bilateral leg and right arm weakness, left upper extremity numbness, and urinary urge incontinence. She denied headache, neck and shoulder pain, and orthostatic symptoms. Examination revealed a moderately severe, right-predominant, asymmetric spastic quadriparesis with generalized hyperreflexia, bilateral extensor plantar responses, and mild …

Uniportal and biportal endoscopic thoracic sympathectomy

SYMPATHECTOMY FOR TREATMENT of hyperhidrosis and pain syndromes of the upper extremities has recently evolved from invasive open procedures to endoscopic procedures. These minimally invasive techniques also have evolved, from complex staged procedures with multiple ports to more simplified biportal and uniportal procedures that require minimal tissue disruption and more limited yet effective sympathectomy procedures. We describe our techniques, experience, and results using endoscopic sympathectomy procedures with further reduced invasiveness, morbidity, and complications.

Iatrogenic intradural spinal arachnoid cyst as a complication of lumbar spine surgery: Report of 2 cases

Iatrogenic spinal arachnoid cysts are rare, but have been described as a complication of spinal injection and lumbar puncture procedures. The authors describe 2 cases of iatrogenic spinal arachnoid cyst formation that occurred after incidental durotomy during lumbar spine surgery. In both cases, postoperative MR imaging revealed compression of the cauda equina by an intradural arachnoid cyst. Intradural exploration and fenestration of the arachnoid cyst was accomplished in each case. This entity should be considered in the differential diagnosis of a patient experiencing symptoms of neurological compression after a lumbar surgery complicated by incidental durotomy.

Superficial siderosis mimicking amyotrophic lateral sclerosis.

We report a case of superficial siderosis erroneously diagnosed as amyotrophic lateral sclerosis. The patients symptoms began 18 years prior with unilateral upper extremity weakness, fasciculations, and hyperreflexia. The patient then developed ataxia and hearing loss 15 years after his original symptoms. The magnetic resonance images revealed superficial siderosis involving the spinal cord and brain. We want to attract attention to superficial siderosis as a rare amyotrophic lateral sclerosis mimic disorder.

Minimally Invasive Intradural Spinal Dural Arteriovenous Fistula Ligation

BACKGROUND Dural arteriovenous fistulas (DAVFs) have traditionally been approached through a bilateral laminectomy procedure with intradural exploration and ligation of the fistulae. A minimally invasive approach for DAVF ligation may be associated with fewer complications and a shorter recovery than the traditional laminectomy procedure. Our objective was to determine the feasibility, safety, and efficacy of intradural DAVF ligation via the use of a minimally invasive microsurgical technique. METHODS Seven patients with thoracolumbar DAVFs were microsurgically treated with a minimally invasive technique. The procedure entailed localization with the use of fluoroscopy followed by a midline 2.2-cm skin opening. Exposure was facilitated by the use of a tubular retractor. Intradural access was obtained after hemilaminectomy, and the fistula was identified and ligated. Dural closure was facilitated by the use of self-closing nitinol clips. The incidence of postoperative complications, blood loss, and length of hospital stay were reviewed. RESULTS Each patient tolerated the procedure well. There were no intraoperative or postoperative complications. Specifically, there were no new neurological deficits and no cerebrospinal fluid leaks. Each patient was ambulatory within 18 hours with only mild incisional back pain. Mean length of stay was 1.6 days. One-year follow-up demonstrated obliteration of the fistula with improvement or stabilization of neurological deficits in all cases. CONCLUSIONS The minimally invasive approach for intradural ligation of DAVFs appears to be a reasonable alternative to bilateral full laminectomies. Although no direct comparison with the more extensive bilateral laminectomy approach has been performed, our initial experience suggests that this novel approach may reduce blood loss and length of hospital stay.

Perplexing Lesions of the Sinonasal Cavity and Skull Base IgG4-related and Similar Inflammatory Diseases

Objective IgG4-related disease (IgG4RD) causing sinonasal and skull base pathology is uncommonly described. We present a series of suspected IgG4RD patients, with a pertinent review of the literature to highlight diagnostic challenges. Study Design Case series. Setting Academic tertiary care center. Subjects and Methods Case series of patients with IgG4RD or suspected IgG4RD involving the sinonasal cavity and skull base. Results We present 4 patients with atypical sinonasal and/or skull base disease who were noted to have IgG4-positive plasma cell infiltration on immunohistochemistry of biopsy specimens. IgG4RD, a recently described entity affecting multiple organs, is characterized by lymphoplasmacytic infiltration and often elevated serum IgG4. IgG4RD can masquerade as malignancy or infection but responds to glucocorticosteroid and immunosuppressant therapy. IgG4RD has been infrequently reported presenting as sinonasal or skull base lesions, and definitive diagnostic criteria for these regions are not established. In our series, IgG4RD was suspected in all 4 patients, but only 1 met all current criteria for definitive diagnosis. All 4 patients, however, responded to corticosteroid therapy, and 1 was placed on long-term azathioprine. Conclusion IgG4RD is rarely described in the sinonasal cavity and skull base, and specific diagnostic criteria for such disease have not been defined. We present a series of patients with IgG4-positive plasma cell inflammatory pathology who were suspected to have IgG4RD. Our series highlights diagnostic challenges associated with these patients. Tumefactive and destructive sinonasal-skull base lesions with a plasma cell-rich infiltrate should incite suspicion of IgG4RD, and immunohistochemistry for IgG4-positive plasma cells should be performed.