Case Of Cerebrospinal Fluid Leak Research Articles

Outcomes following Aggressive Surgical Resection of Intra-Medullary Spinal Cord Tumours with Intra-Operative Neuro-Monitoring

Introduction: Intra-medullary spinal cord tumours (IMCST) are relatively uncommon tumours of the central nervous system which can result in severe neurological disorder if untreated. Histologically, IMCSTs are often either biopsied or excised subtotal, but this may lead to early tumour recurrence and progressive neurological impairment. In an attempt to improve outcomes, the recent trend is to perform more radical tumour resection guided by intra-operative monitoring (IOM). However, there are no controlled studies comparing the resection of IMCSTs with or without IOM. In this single surgeon series, we analyse outcomes following optimal resection of IMCSTs in conjunction with IOM. Methods: In this retrospective single surgeon series, case notes and history of patients who underwent surgery between 2006–2012 at the Singapore General Hospital's Neurosurgery Department, were studied. IOM with somatosensory evoked potential (SSEP) and motor evoked potential (MEP) were utilised to facilitate optimal tumour resection. Neurological status were compared pre- and post-operatively with long-term follow-up on outcomes. Magnetic resonance imaging was used pre- and post-operatively to assess the degree of tumour resection. Results: Thirteen consecutive patients with IMCSTs (five males, mean age 36 years, range 12–60) underwent surgical treatment and were included in this study. Radical surgical resection was performed for 11 patients, while the remaining two had biopsies and partial debulking as frozen section showed high grade astrocytomas. Histology revealed six cases of ependymoma, five cases of astrocytoma, and one of hemangioblastoma and neuroenteric cyst. There was one case of wound infection which was treated successfully. There were no cases of cerebrospinal fluid leakage. Two patients had pre-existing spinal deformity, and underwent posterior instrumented fusion concomitantly. The neurological state improved or remained stable in 11 (85%) patients, and two patients had immediate post-operative neurological deterioration which improved subsequently with physiotherapy over one to two months. Favourable functional outcomes were observed in the majority of patients during follow-up. The patients with high grade tumours were treated with adjuvant radiotherapy post-operatively, however, they showed a poorer long-term outcome. The mean follow-up was 3.2 years from operation. Conclusion: Radical resection of intra-medullary tumours with IOM leads to a favourable functional outcome in selected groups of patients.

The role of sinus surgery in children

To critically review the current literature discussing the outcome of endoscopic sinus surgery (ESS) in children with chronic rhinosinusitis (CRS). Literature review. PubMed database and the Cochrane Library were searched. The PubMed search included all English-language literature published between January 1990 and July 2012 discussing the role of ESS in children with CRS. Studies that included patients with cystic fibrosis, primary immunodeficiency disorders, or ciliary dysmotility disorders were excluded. Of the 507 articles retrieved from the primary research strategy, 11 studies were included for further discussion. There were no randomized controlled studies. The rate of success of pediatric ESS ranged from 82% to 100% in selected patients. Children undergoing ESS for CRS usually have more severe disease compared to those who get medical treatment or adenoidectomy. The extracted rate of complication was 1.4%, with no cases of cerebrospinal fluid leak or major orbital injury such as hematoma or blindness reported. ESS offers a surgical alternative in the treatment of CRS in children with an excellent safety profile. There remains a need for higher level studies addressing the indications of ESS in children.

En bloc open-door laminectomy and pedicle screw fixation for extremely severe cervical ossification of posterior longitudinal ligament

Objective To evaluate the effect of en bloc open-door laminectomy and pedicle screw fixation for extremely severe cervical ossification of posterior longitudinal ligament (OPLL).Methods From January 2007 to December 2011,16 cases of serious cervical OPLL were treated,in which there were 13 males and 3 females,aged from 45 to 74 years (average,56.5 years).Spinal cord functional deterioration was related to minor activities of the neck,such as sneeze,cough or hyperextension of the neck,in 15 cases.One case suffered from aggravating neurological symptoms without a definite precipitating factor.The average preoperative Japanese Orthopaedic Score (JOA) was 7.1 ±1.8.Preoperative CT scans displayed the average stenotic rate (thickness of OPLL/sagittal diameter of the spinal canal) was 83.7％.All the patients received en bloc laminectomy and pedicle screw fixation of the cervical spine.Results All the patients were followed up for 3 months to 4 years (average,24.4±10 months).The JOA scores at 2 weeks,3 months,and the last follow-up postoperatively were 13.2±1.7,13.5 ±1.6 and 14.1 ±1.5,respectively; the improvement rates were 61.6％,64.6％ and 70.7％,respectively.The operative time ranged from 80 to 150 minutes (average,130 minutes),and blood loss ranged from 150 to 600 ml (range,300 ml).One case of postoperative wound hematoma,1 case of cerebrospinal fluid leakage and 3 cases of trapezius muscle pain occurred in this group.No serious complications,such as deep infection,deterioration of neurological dysfunction,vertebral artery injury and internal fixation failure,were noticed.Conclusion Owing to the minimum interference to the cervical spinal cord,stabilization of the decompressed segments and maintenance of cervical lordosis,en bloc open-door laminectomy and pedicle screw fixation is suitable for extremely severe cervical OPLL. Key words: Cervical vertebrae; Ossification of posterior longitudinal ligament; Bone screws

The Ultrasonic Bone Aspirator in Transnasal Endoscopic Dacryocystorhinostomy

To evaluate the outcomes of endoscopic dacryocystorhinostomy (eDCR) with and without the use of ultrasonic bone aspirator (UBA; Sonopet). A retrospective, institutional review board approved chart review of all eDCRs over 49 months. Data included demographics, indication/etiologic factors of nasolacrimal duct obstruction, comorbidities, intraoperative findings, epiphora symptoms pre- and postoperatively, and complications. Patients were grouped in eDCR with or without UBA. One hundred and twenty-three primary eDCRs in 99 patients were included, 59 with UBA and 64 without UBA. Most patients were Caucasians (80.8%) and women (72.0%), with a mean age of 55.9 years (range, 9-89). There were no significant differences in the demographics of the 2 subgroups. Complete resolution of symptoms was obtained in 81.3% of procedures without UBA and in 79.7% with UBA. Most patients (72.7%) were deemed idiopathic preoperatively. Lacrimal sac biopsy demonstrated significant pathologic factors in 9 (7.3%) cases, with 7 (5.7%) of these resulting in a new diagnosis for the patient. There were no cases of cerebrospinal fluid leakage, visual loss, diplopia, infection, or uncontrolled epistaxis in either group. Early results of eDCR with UBA appear to show reasonable efficacy. The overall success and failure rates of eDCR with and without UBA are similar. Neither group had any complications in this study, although any conclusion on the overall safety of the procedure is limited by the power of this study.

The diagnosis and surgical treatment of occult otogenic CSF leakage

Conclusions: The diagnosis of occult otogenic cerebrospinal fluid (CSF) leakage is challenging and it can easily be misdiagnosed. Some characteristics of clinical presentation can supply important clues and confirmed diagnosis should be obtained according to these clues and suitable imaging studies before meningitis develops. Different surgical techniques should be adopted to treat the CSF leakage according to different leakage etiologies, and good results can be obtained. Objective: The aim of the study was to evaluate the diagnosis and surgical treatment of occult otogenic CSF leakage, including the characteristics of clinical presentation, imaging studies, and operation methods in order to decrease the rate of misdiagnosis and obtain a good curative effect. Methods: We performed a retrospective review of 11 cases of CSF leakage that were all misdiagnosed and accompanied by meningitis, operated in our department from 2007 to 2012 after a mean follow-up of 3 years. In this context, the characteristics of clinical presentation, imaging studies, and management of CSF leakage were studied. Results: The CSF leakage had arisen traumatically (n = 9) or congenitally (n = 2). The medical history and special clinical presentation such as repeated otorrhea or rhinorrhea, fever, headache, and unilateral deafness can supply important diagnostic clues. Imaging studies including high-resolution noncontrast CT (HRCT), CT cisternography, and magnetic resonance imaging (MRI) are very important diagnostic methods. The surgical repairs were performed via a transmastoid approach (n = 8), packing the vestibule (n = 1) or a translabyrithine approach (n = 2). Recurrent leakage did not occur.

Transotic approach in acoustic neuroma surgery

Objective To evaluate the advantages of transotic approach in acoustic neuroma surgery.Methods A retrospective analysis of patients with acoustic neuroma in our hospital between July 2007 and March 2012 were performed.These patients were undergone evaluation of PTA,facial nerve function,temporal bone CT,inner ear MRI before operation.There were 32 patients,who have a hearing loss more than 50 dB,or a tumor size larger than 2 cm,which made the preservation of hearing function impossible.Low middle cranial fossa,forward sigmoid sinus and high bulb of jugular vein were showed in preoperative CT scan.These patients were picked to have acoustic neuroma resection by transotic approach.Results The radical tumor resection rate was 94％ (30/32).The facial nerve structure prescrvation rate was 100％.After the surgery,all patients were single -side deaf.Some patients experienced vertigo,which was relieved after treatment.There was no severe complication such as death,hemiplegia,or intracranial infection.However,there were one case of intracranial hemorrhage and one case of cerebrospinal fluid leakage,which were cured by revision surgery.Conclusions For those who has a worse pneumatolytic temporal bone,which presents with low middle cranial fossa,forward sigmoid sinus and high bulb of jugular vein in CT scan,if it is impossible or there is no need for the preservation of the hearing function,the transotic approach may be considered for better radical removal of tumor,preservation of facial nerve and reduction of cerebrospinal fluid leakage. Key words: Transotic approach ; Acoustic neuroma; Facial nerve preservation ; Cerebrospinal fluid leakage

A survey on spinal cord injuries resulting from stabbings; a case series study of 12 years' experience

:Background:Penetrating spinal cord injuries (SCIs) are an uncommon injury and not reported very frequently. SCIs cause sensory, motor and genitourinary system problems or a combination of sensorimotor dysfunctions. These are among the most debilitating kinds of disorders and negatively affect quality of life, not only for the patient, but also for their family members. Therefore, the present study aims to evaluate complete or incomplete SCIs and the course of the injury and the prognosis for SCIs caused by stab wounds.Methods:This case-series design study was performed on 57 patients attending the emergency department of Taleqani Trauma Center (Kermanshah, Iran) due to SCIs caused by violent encounters involving sharp objects such as a knife, dagger, whittle and Bowie-knife between 1999 and 2011. An assessment of sensory and motor functions was performed as part of the neurological examination on admission, and during the treatment, using the Frankel Classification grading system, and the results were recorded.Results:The average age of patients was 27 years (SD= 7.9, Range=17 to 46 years). The results of the study showed a proportion of cervical, thoracic and lumbar injuries of 23 (40%), 24 (42%) and 10 (18%), respectively. There was no case of cerebrospinal fluid leakage (CSF) or infection at the wound site in the subjects. Regarding the extent of the SCI, the combined neurological assessment showed that several patients (43%) had a complete SCI with no sensory and motor functions in the sacral segments and the segments below the site of injury. In 32 patients (57%) incomplete injuries were observed; i.e. they showed only some degrees of sensory-motor functions that were below the neurological level.Conclusions:Both complete and incomplete SCIs are of great importance because the prognosis of SCI is directly associated with the location and extent of injury. It should be considered that partial recovery from SCIs is possible in few cases of complete injuries. Therefore, all the patients should be treated carefully and seriously.

Surgical options and clinical outcomes of cervical ossification of the posterior longitudinal ligament

To discuss the options and clinical outcomes of surgical treatment of cervical ossification of the posterior longitudinal ligament (OPLL). From January 2006 to December 2010, 63 patients of cervical OPLL treated surgically by same team were retrospectively analyzed. There were 49 males, 14 females, with a mean age of 56.2 years (from 38 to 76 years). The duration of symptoms ranged from 2 months to 20 years (mean 3.2 years). The ossified ligament was classified via sagittal and coronal images on CT scan. The cervical curvature was measured. Choice of surgical methods was determined according to the type of ossified ligament and cervical curvature. All complications occurred was recorded. The Japanese Orthopedic Association (JOA) scoring system was used to evaluate the neurological status. The severity of cervical pain was assessed with visual analogue scale (VAS) method. The results of preoperative, postoperative and follow-up were statistically compared with student t test. The JOA scores of 35 patients performed with anterior approach improved from 9.8 ± 2.3 preoperatively to 11.7 ± 2.1 at final follow-up (t = 3.28, P < 0.05). The VAS sore was significantly decreased at final follow-up compared with preoperative (t = 3.15, P < 0.05). While the JOA scores improved from 10.4 ± 2.7 preoperatively to 12.5 ± 2.3 at final follow-up (t = 3.81, P < 0.05) in 12 patients with laminectomy and from 9.7 ± 2.5 to 11.6 ± 2.6 in 14 patients with laminoplasty (t = 3.56, P < 0.05). The VAS score either in laminectomy or in laminoplasty has not significantly difference between preoperative, 3 month postoperative and final follow-up (P > 0.05). Two patients underwent a combined anterior-posterior approach procedure. Complications in patients included 1 patient of postoperative neurologic deterioration and 2 cases of cerebrospinal fluid leakage in patients with anterior approach, and 2 cases of C(5) nerve palsy in patients with laminectomy. Surgical options of cervical OPLL should be determined by detailed study of type and range of ossified ligament, as well as the cervical curvature of patients. Good neurological function can be expected in case of appropriate choosing the method for treating the cervical OPLL.

Oxiplex Reduces Leg Pain, Back Pain, and Associated Symptoms After Lumbar Discectomy

Prospective, randomized, blinded clinical trial. To evaluate effectiveness of Oxiplex gel for reduction of pain and associated symptoms after lumbar discectomy. Oxiplex gel (carboxymethylcellulose, polyethylene oxide, and calcium) is used during discectomy to coat the surgical site for reduction of pain and symptoms after lumbar discectomy. Patients undergoing single-level lumbar discectomy performed by laminectomy or laminotomy and randomized to receive either surgery plus Oxiplex gel (treatment group) or surgery alone (control group) were assessed 6 months after surgery using (1) a quality of life questionnaire (Lumbar Spine Outcomes Questionnaire [LSOQ]) and (2) clinical evaluations. There were no statistically significant differences in baseline demographics, surgical procedures, LSOQ scores, and clinical evaluations between treatment (N = 177) and control (N = 175) groups. More gel-treated patients were satisfied with outcome of their surgical treatment than control patients (P = 0.05). The gel-treated group showed greater reductions in pain and symptoms from baseline compared with surgery-only controls. Additional benefits of gel were consistently shown in reduction of leg and back pain at 6 months in the patient population having substantial back pain at baseline (greater than or equal to the median LSOQ pain score of 63). In that population, there was a statistically significant reduction of leg pain and back pain (P < 0.01) in the treatment group compared with controls. Fewer patients in the treatment group had abnormal musculoskeletal physical examinations at 6 months compared with controls. There were no cases of cerebrospinal fluid leaks and no differences in laboratory values or vital signs. Patients in the treatment group had less hypoesthesia, paraesthesia, sensory loss, and fewer reoperations during the 6-month follow-up than controls (1 vs. 6). These data demonstrate improvements in clinical outcomes resulting from the use of Oxiplex gel in discectomy procedures for treatment of lumbar disc herniation.

Fatal Drip: Sinusitis and Meningitis

MRI brain coronal view of left superior ethmoid cell defect.A 48-year-old woman presented to the emergency department complaining of a five- to six-week history of persistent nasal drip, with fever and intermittent headaches for one month. She described a throbbing occipital headache radiating to the periorbital area bilaterally. She had been treated with several different antibiotics in the preceding four months for a presumptive diagnosis of sinusitis. Symptoms improved while on the medication, but then would quickly return once the antibiotic course was finished. At presentation, the patient had a temperature of 102.0°F, and her skin was flushed and hot to the touch. She appeared uncomfortable, lying on the stretcher holding her head. Nasal congestion with surrounding erythema and clear rhinorrhea were noted. Her tympanic membranes were normal bilaterally, and her pharynx appeared normal with no tonsillar hypertrophy or exudate. Her neck was supple with no tender lymphadenopathy. Her heart maintained normal rhythm and rate, and her lungs were clear to auscultation bilaterally. She was neurologically intact. The rest of her physical exam was unremarkable. Laboratory studies demonstrated a leukocytosis of 23.6 × 103/mcL with 89% segmented neutrophils and 6% lymphocytes. Besides an elevated alkaline phosphatase at 158, the rest of her laboratory evaluation and a CT scan of her brain were unremarkable. A lumbar puncture was attempted but unsuccessful. Ceftriaxone 2 g was given, and the patient was admitted for an MRI and fluoroscopic-guided lumbar puncture. An MRI of the brain subsequently demonstrated a left superior ethmoid cell defect causing CSF leakage through the ethmoid sinuses. (Photo.) CSF analysis was suggestive of bacterial meningitis, but no organisms were found. She was transferred to a tertiary care facility where she was successfully treated with endoscopic endonasal repair without recurrence of symptoms. Cerebrospinal fluid (CSF) fistulas can occur from traumatic and atraumatic causes. Although the occurrence of a CSF fistula is rare, traumatic causes are the most common etiology, occurring in 70 to 80 percent of cases. CSF fistulas can also occur from eroding tumors, congenital defects, ENT infections, or increased intracranial pressures such as those with pseudotumor cerebri. In any of these cases, there is a destruction or breakdown of the bony architecture resulting in a defect of the cribriform plate. Immediate action is necessary to prevent ascending meningitis, which occurs in a third of patients with CSF leaks. Whatever the cause of a CSF leak, patients most commonly present with unilateral clear rhinorrhea, which can easily be confused for allergic rhinitis. The fluid may be tested for beta-2 transferrin to confirm the CSF leak. The second most common presentation is active meningitis or a history of meningitis. Defects are most commonly in the sphenoid sinus and the ethmoid roof. Management depends on etiology. If due to traumatic events, patients who present with small fistulas may be treated conservatively with head elevation, bed rest, and antibiotics. For those who do not respond to conservative management or who have large or nontraumatic fistulas, immediate surgical repair is needed. IV acetazolamide is given for those with pseudotumor cerebri to attempt to decrease intracranial pressure. A VP shunt is placed for those who present with recurring leaks or who do not respond appropriately to diuretics. The etiology of this patient's CSF leak still remains uncertain. There was no recent trauma to suggest that a physical defect occurred. Cases of CSF leaks have been known to occur 20 years after a traumatic head injury, however, and this patient admitted to such an event 22 years previously. According to the patient, past CT scans and MRIs of the brain were negative, although small fistulas may be missed by radiological studies. Our patient was also obese, and admitted to occasional headaches, which may also suggest pseudotumor cerebri as a cause. Our patient also had a history of sinus infections for more than four months, which also could be the source of the defect. Unfortunately, the mystery remains on whether the leak was present prior to the sinusitis causing similar symptoms. One thing, however, is certain. The multiple courses of antibiotic regimens that she received saved her life. The authors are from the emergency medicine residency at Good Samaritan Hospital Medical Center in West Islip, NY.

Juvenile Nasopharyngeal Angiofibroma with Intracranial Extension

To provide a critical evaluation of the historical evolution of the surgical treatment of juvenile nasopharyngeal angiofibroma (JNA) with intracranial extension. Case series with chart review. Skull base multidisciplinary group at the Instituto de Neurologia de Curitiba, Brazil. From 1988 to 2000, the multidisciplinary skull base group surgically treated 67 adolescent boys with JNA, 20 of whom presented with intracranial extension. All patients presented involvement of the cavernous sinus, and 5 of them spread into the orbit. Before 2008, the authors combined microscopic-endoscopic techniques. After this period, the surgical approach used was facial degloving, associated with purely endoscopic technique patients. Total tumor removal was achieved in 17 cases in the first surgery. In this series, the intracranial extension was extradural in all cases. There was only 1 case of cerebrospinal fluid leakage, which was promptly identified and treated. There was no mortality or permanent morbidity. Radical removal of large JNA may be difficult because of its extreme vascularity and extension to the cavernous sinus, orbit, middle and anterior fossa. Nevertheless, most of JNA with intracranial extension can be resected in the first operation with minimal morbidity through a facial degloving and further combination of expanded endoscopic endonasal approaches.

Complicaciones postquirúrgicas de la malformación de Chiari tipo I: duroplastia y fístula de líquido cefalorraquídeo

The surgical treatment of Chiari I malformation is to carry out a suboccipital decompression. It is described that postoperative complications may occur, especially if the dura is open and closed using a graft (duraplasty). Among them, one of the most important events due to its difficult handling is cerebrospinal fluid leak through the suture line. To conduct a postoperative review to analyze the outcome of the patients and the occurrence of complications depending on the dural plasty used. A retrospective study was carried out between 1997 and 2008, both inclusive, where we assessed 36 patients. All of them were studied with preoperative and postoperative craniospinal magnetic resonance, and by a thorough clinical examination performed before and after the surgery. The surgical procedure consisted of suboccipital decompression and resection of the posterior arch of C1 or C1 and C2 (depending on the extent of the caudal displacement of the tonsils), followed by duraplasty using either an autologous graft (pericranium) or a synthetic graft (Gore-tex). After a mean follow-up of 2 years, the clinical results were: excellent (55%), if there was a great clinical improvement; good (29%), if there was slight improvement; and bad (16%), if there was no improvement or there was worsening. In the 30 patients given a duraplasty (18 with an artificial graft, 12 with an autologous pericranium graft), 6 cases of cerebrospinal fluid leak appeared, although no significant association between the type of dural plasty and the presence of leak was observed. The best results were obtained for headaches, cervical pain and dizziness. Despite the fact that there were more cases of cerebrospinal fluid leak in patients receiving an artificial graft compared to patients with pericranium graft, there was no significant difference.

Utility of a Three-Dimensional Endoscopic System in Skull Base Surgery

We evaluated the utility of a three-dimensional (3-D) endoscopic system for skull base surgery. We performed a retrospective case series in a tertiary care medical center. Thirty-six patients underwent skull base (nonpituitary) resections via 3-D endoscopic system. Fifteen patients (42%) were operated for excision of malignant tumors, 19 (53%) for excision of benign lesions, and 3 (8.3%) for skull base reconstruction. The tumors involved the cribriform plate (n = 13), sphenoid sinus and planum (n = 17), clivus (n = 7), and sella (n = 7). Complete tumor resection was achieved in 31 patients and subtotal resection in two. Five patients (14%) had postoperative complications. There was one case of meningitis, and there were no cases of cerebrospinal fluid leak. The surgeon's ability to recognize anatomic structures at the skull base was evaluated using the 3-D and two-dimensional systems. The 3-D technique was superior to the conventional technique for identification of the sella, carotid prominence, optic prominence, cribriform plate, sphenoid, and fovea ethmoidalis. The two systems were equal for detection of the turbinates, clivus, maxillary, ethmoids, and frontal sinuses. Endoscopic skull base surgery with stereoscopic viewing is feasible and safe. Further studies are required to evaluate the advantage of binocular vision in skull base surgery.

A Novel Method of Translabyrinthine Cranioplasty Using Hydroxyapatite Cement and Titanium Mesh: A Technical Report

We report a novel technique for closure using titanium mesh cranioplasty in addition to hydroxyapatite cement and abdominal fat graft for acoustic neuroma. We reviewed 15 patients who underwent translabyrinthine craniectomy for resection of acoustic neuroma. Hearing loss was documented prior to surgical procedure. Over 2 years, patients underwent titanium mesh and hydroxyapatite cranioplasty with abdominal fat graft. Participants included seven men and eight women, age range 38 to 65. Main outcome measures included cosmetic outcome and incidence of cerebrospinal fluid (CSF) leak. The lesion was right-sided in seven patients and left-sided in eight. Cosmetic outcome was excellent in all. There were no cases of CSF leak. Closure used one-third the hydroxyapatite required for traditional closure. Our technique yields cosmetic results equivalent to hydroxyapatite cement alone and a comparable incidence of CSF leakage without leaving a drain in place postoperatively. The technique is easy to adopt, is more cost-effective than hydroxyapatite cement cranioplasty alone, offers greater ease of access for reoperation, and does not preclude later implantation of bone-anchored hearing aid.

The clinical analysis of Posterior mini-incision surgery for the single segment of the lumbar disc herniation

Objective To explore the treatment and clinical characteristic of posterior mini-incision surgery for the single segment of the lumbar disc herniation.Methods Clinical data of 260 cases with single segment lumbar disc herniation were analyzed retrospectively.Results Follow-up for 6 months to 5 years,with an average of 24 months.According to Nakai effect criteria,109 cases of excellent,good in 132 cases,17 cases of fair,two cases of poor,12 cases of cerebrospinal fluid leakage,2 cases of wound hematoma,one case of vertebral space infection,resulting in 92.7%.Conclusion Advantages of posterior mini-incision surgery for the single segment of the lumbar disc herniation are small incision,less trauma,shorter operative time,less bleeding,quick recovery and low costs.Stressed the need to accuratel position preoperation. Key words: lumbar vertebrae; Surgical procedures; oper ative

Endoscopic endonasal surgery in the management of selected malignant naso-ethmoidal tumors

Objective The objective of this study was to report the cases of three patients with sinonasal malignant tumors who underwent en bloc tumor resection using endoscopic endonasal approaches, and to discuss the advantages and limitations of endoscopic endonasal tumor resection. Methods Three patients with malignant naso-ethmoidal tumors underwent en bloc resection with endoscopic endonasal approach. Results In very carefully selected cases of naso-ethmoidal malignant tumors that were preoperatively evaluated on endoscopic findings and magnetic resonance imaging to be limited to within the nasal cavity and/or ethmoid sinus and to have some safe margins between the tumor and skull base and/or lamina papyracea, tumors were resected en bloc using endoscopic endonasal approaches. A case of cerebrospinal fluid leakage was safely managed with the endoscopic approach. Conclusions In selected T1–T2 naso-ethmoidal malignant tumors with some safe margins, endoscopic endonasal surgery may offer a satisfactory alternative to external procedures.

Triological thesis: concurrent endoscopic sinus surgery and cosmetic rhinoplasty: Rationale, risks, rewards, and reality

To examine the effect of concurrent endoscopic sinus surgery (ESS) on the postoperative course of cosmetic rhinoplasty (CR), identify any specific contraindications, and to develop more useful treatment regimen in patients undergoing concurrent ESS and CR. Retrospective case-control study. Consecutive patients undergoing CR (performed by the principal investigator (PI) in a tertiary care academic practice) at the same operative setting as ESS from June 2004-June 2007 were identified. Additionally, patients undergoing CR (also by the PI) without ESS over the same time period (matched for gender, age, and rhinoplasty approach and techniques) were identified and used as control subjects. The office and hospital charts of these patients were reviewed for details of pre-, intra-, peri-, and postoperative care, preoperative CT scans as well as for patient and physician observations. Specifically noted were details regarding the type of cosmetic changes sought, course of symptoms of chronic sinusitis, prior treatment, surgical techniques used for both ESS and CR, and postoperative treatment with antibiotics and corticosteroids. Additionally, a literature review of articles describing concurrent CR and ESS was performed. Thirteen patients were identified who underwent ESS at the same time as CR. There were no cases of cerebrospinal fluid leak, epistaxis, orbital complications, septal perforation, cellulitis or saddle nose deformity. No correlation was found between sinus surgery performed and need for revision surgery (CR or ESS) or postoperative infections. However, the time to patient reported resolution of postoperative nasal swelling was significantly higher in patients undergoing concurrent ESS/CR compared to CR only (dorsal swelling: 9.62 +/- 6.18 (ESS/CR) vs. 5.85 +/- 1.95 (CR) weeks, P = .0469; nasal tip swelling: 19.31 +/- 13.02 (ESS/CR) vs. 10.38 +/- 2.96 (CR) weeks, P = .0240, unpaired t test). The same relation held true for doctor noted postoperative edema (nasal dorsal edema: 10.62 +/- 7.32 (ESS/CR) vs. 6.31 +/- 2.72 (CR) weeks, P = .0582; nasal tip edema: 21.46 +/- 15.66 (ESS/CR) vs. 12.23 +/- 4.10 (CR) weeks, P = .0508, unpaired t test). Among patients who underwent concurrent ESS and CR, this time was highly correlated with the severity of sinus disease on preoperative CT scanning (r(2) = 0.8573, P < .0001). A greater need for postoperative corticosteroid injections in the ESS/CR group was suggestive but not statistically significant (30.8% vs. 0%, P = .0957). While our data supports concurrent ESS and CR as safe, our findings suggest that the presence and treatment of concurrent sinonasal disease prolongs the patients' recovery from CR. This may be due to the effects of sinus pathology and manipulation of sinonasal venous and lymphatic drainage patterns or could be due to subclinical infectious soiling of rhinoplasty tissue planes. We recommend a two-team approach to promote excellent surgical technique, avoid surgeon fatigue, and enhance patient care. We recommend adequate medical management of chronic sinusitis prior to surgery, pre, intra and postoperative antibiotic coverage, appropriate postoperative sinus toilet beginning 1 week after surgery and careful and close patient follow-up to optimize results. Most importantly, we advocate close coordination of sinonasal and rhinoplastic care in a two-team approach to maximize care.

Surgical Results of Intradural Extramedullary Tumors

BackgroundTo report the treatment results of 12 patients who underwent a total excision of intradural extramedullary tumors.MethodsTwelve cases of histopathologically confirmed intradural extramedullary tumors were treated surgically between February 2002 and March 2005. There were 8 males and 4 females with an average age of 42.6 years. The mean postoperative follow-up period was 24.2 months. The histopathological findings, locations of the tumors, and clinical results were analyzed. The neurological findings obtained during the preoperative stage and the postoperative follow-up were evaluated according to the Frankel classification.ResultsThe histopathological results are as follows: 4 cases of a meningioma, 4 cases of a schwannoma, 2 cases of an epidermoid cyst, 1 case of an arachnoid cyst, and 1 case of an ependymoma. The locations of the tumors were as follows: 7 cases in the thoracic region, 4 cases in the lumbar region, and 1 case in the cervical region. At the final follow-up, a 2-grade and 1-grade improvement was observed in 1 and 7 cases, respectively. There were no changes in the Frankel grade in 4 cases. The preoperative neurological deficit improved within 8 postoperative weeks in most cases and within 1 postoperative year in all cases. Postoperatively, there were 2 cases of cerebrospinal fluid leakage and 2 cases of paresthesia.ConclusionsIntradural extramedullary tumors detected by MRI are mostly benign and good clinical results can be obtained when treated surgically. Therefore, more active surgical approaches by orthopedic surgeons are recommended to decrease morbidity.

Late-Onset Occult Cerebrospinal Fluid Leakage After Orbital Exenteration

Orbital exenteration can be complicated by cerebrospinal fluid leakage, mostly during surgery. Late-onset cerebrospinal fluid leakage that occurs years after the initial orbital exenteration is rare. The authors report a case of cerebrospinal fluid leakage that occurred 4 years after orbital exenteration that was not due to tumor recurrence. The leakage was managed successfully by the application of cyanoacrylate tissue glue. No complication was encountered.

Cerebrospinal Fluid Leaks in Orbital and Lacrimal Surgery

Cerebrospinal fluid leakage is an uncommon but significant complication of orbital and rarely lacrimal surgery which may have serious consequences including death. In a retrospective review of four orbital units, we report an incidence of cerebrospinal fluid leak (diagnosed intraoperatively) during exenteration, orbital decompression, and dacryocystorhinostomy of 1/154 (0.6%), 4/397 (1%), and 0/3,504 (0%), respectively. We found two additional cases of cerebrospinal fluid leaks associated with excision of orbital masses involving the orbital roof. In the literature, the incidence of cerebrospinal fluid leaks associated with orbital exenterations and decompressions was 1.6–16.7% and 0–10%, respectively. Cerebrospinal fluid leaks occur very rarely in dacryocystorhinostomies with only a few case reports found in the literature. Preventative measures, diagnosis, and management of this complication are discussed. Knowledge of anatomy and thorough preoperative assessment may predict areas at high risk for encountering cerebrospinal fluid leaks. Proper surgical technique further minimizes the risk for this complication. If a cerebrospinal fluid leak occurs, however, prompt diagnosis and management usually results in uncomplicated recovery.