Cranial Extension Research Articles

Lateral Lumbar Interbody Fusion for the Correction of Spondylolisthesis and Adult Degenerative Scoliosis in High-Risk Patients: Early Results and Complications

Introduction Lateral lumbar interbody fusion (LLIF) by a transpsoas approach can avoid complications seen in other techniques. Lateral cages offer a larger cage and may increase stability by spanning the ring apophysis. Patients with multiple comorbidities, including smoking, diabetes, and obesity, have been shown to have decreased fusion rates. This study used computerized tomography (CT) scans to assess interbody fusion utilizing the LLIF technique in patients at high risk for nonunion and pseudoarthrosis. Methods We performed a retrospective review of patients who underwent LLIF between January 2008 and December 2013. A total of 64 patients with 151 levels underwent nonstaged or staged LLIF with posterior correction and augmentation. Per protocol, patients received CT scans at their 1-year follow-up. Of the 64 patients, 32 patients with 86 levels met inclusion criteria. Two board-certified musculoskeletal radiologists and the senior surgeon (J. Z.) assessed fusion. Results We performed six revision surgeries (18.75%). Other comorbidities included osteopenia/osteoporosis (46.8%), diabetes (25%), obesity (25%), and active smoking (25%), among others. Postoperative complications occurred in 15 patients (46.8%). Anterior thigh pain and weakness occurred in five patients (15.6%), all of which resolved by 6 months. There were five cases of delirium/postoperative confusion (15.6%). There were three cases of proximal junctional kyphosis, each requiring revision and cranial extension. Two cases of abdominal atonia occurred, one of which resolved at 1 year and the other still symptomatic at 1 year and 1 month. There were no cases of infection, ileus, UTI, catastrophic subsidence, DVT or PE. By CT scan assessment, each radiologist found solid fusion, as demonstrated by strong bridging trabeculae, was achieved in 84 out of 86 levels (97.6%). This was in agreement with the senior surgeon (J. Z.). Conclusion Several studies have evaluated LLIF fusion and reported fusion rates between 88 and 96%. Our results demonstrate high fusion rates (97.6%) using this technique, despite multiple comorbidities. Since stability plays a vital role in successful fusion, spanning the ring apophysis with a larger cage, along with pedicle screw supplementation, appear to be key factors.

Anatomy and biomechanics of the craniovertebral junction.

The craniovertebral junction (CVJ) has unique anatomical structures that separate it from the subaxial cervical spine. In addition to housing vital neural and vascular structures, the majority of cranial flexion, extension, and axial rotation is accomplished at the CVJ. A complex combination of osseous and ligamentous supports allow for stability despite a large degree of motion. An understanding of anatomy and biomechanics is essential to effectively evaluate and address the various pathological processes that may affect this region. Therefore, the authors present an up-to-date narrative review of CVJ anatomy, normal and pathological biomechanics, and fixation techniques.

Schwannoma of the nasal cavity: A case report and a review

Nasal polyps constitute the clinical presentation of a variety of soft tissue lesions involving the nose. Benign nerve sheath tumors are rare lesions that can present in the nasal cavity. Herein, we present a rare case of nasal schwannoma, and we review the clinical and the radiological features of cases published as nasal cavity schwannoma in the English literature. Extensive PubMed search revealed only 17 cases of schwannoma of the nasal cavity reported during the period 2000-2013. The mean age of presentation was 39 years, and a female predilection was observed. The main radiological feature was a homogenous well circumscribed mass on plain radiography with intermediate intensity on T1-weighted and T2-weighted and homogenous enhancement on contrast magnetic resonance imaging. No invasive growth pattern or cranial extension was reported. The histological features of nasal cavity schwannomas were similar to their soft tissue counterparts. The literature shows that malignant cases are rare.

Superficial tributary insufficiency of the Giacomini vein causing misinterpretation: A case report with a brief review

Giacomini vein (GV) is an intersaphenous vein that connects lesser saphenous vein cranially to the greater saphenous vein tracking medial side of the leg. It is aimed to emphasize the importance of the diagnostic evaluation regarding the presence and compatibility of this cranial thigh extension of the lesser saphenous vein before planning the treatment modality in lower limb venous insufficiencies. In this case, an 18-year-old female patient diagnosed as an existence of an insufficient GV and the surgical treatment via extirpation of its small popliteal varicose tributary with isolated insufficiency, is presented.

Primary (Poorly Differentiated) Sclerosing Liposarcoma of Temporal Region. An Uncommon Tumor in a Rare Site: A Case Report

Liposarcoma (LS) in the head and neck region is a rare tumor. The sclerosing variant of LS is a subtype of well-differentiated LS characterized by areas of conventional LS admixed with hypocellular areas of stromal sclerosis that show atypical lipomatous cells. The (poorly differentiated) sclerosing LS, on the other hand, is more cellular with atypical, pleomorphic and often bizarre giant tumor cells admixed with atypical lipoblasts. We report a case of poorly differentiated sclerosing LS of temporal region in a 49-year-old man. Radiologically, the tumor was dumbbell shaped with intra and extra cranial extension. In this case, we discuss the clinico-radiological and pathological findings of an unusual tumor in a rare location.

Bezold′s fistula: An unusual presentation of cholesteatoma

Cholesteatoma presenting with a Bezold's fistula is extremely rare, and such presentation has been reported. It is infrequent these days in this era of antibiotics, due to early institution of treatment. Fistula results in untreated and inadequately managed Bezold's abscess. The treatment of Bezold's abscess is with prompt intravenous antibiotics, followed by drainage of cervical abscess, but management that of Bezold's fistula is primarily surgical in which a mastoidectomy is done to eradicate the disease with exposure of the mastoid tip with laying open the fistulous tract. One such unusual case of a Bezold's fistula with cholesteatoma is reported in a teenager with a long-standing history of ear discharge, but without any other complications. The patient had being managed conservatively with ear drops since childhood. High resolution computed tomography (CT) mastoids revealed extensive cholesteatoma is destroying the mastoid and perforating the tip with erosion of the tegmen tympani with extra cranial extension. Patient underwent modified radical mastoidectomy with reconstruction of the mastoid bowl with bone pate. Patient was successfully treated and was followed to 1-year with CT scan without recurrence.

A Good View at Proper Diagnosis: Onodi Cell As Rare Cause of Optic Neuritis

The sphenoethmoidal cell (Onodi cell) is a quite posterior ethmoid cell with more cranial and dorsal extension which leads to dorsal displacement of sphenoidal sinus. Onodi cell shows very close proximity (medial, cranial, and caudal) to the optic canal respectively to the optic nerve.

Extensive Allergic Fungal Rhinosinusitis: Ophthalmic and Skull Base Complications.

To review the clinical features, ophthalmic and skull base complications, radiologic correlates, surgical methods and outcomes in cases of extensive allergic fungal rhinosinusitis (AFRS). The retrospective review was carried out at a tertiary referral center and included 11 patients with extensive AFRS. Inclusion criteria were confirmed cases of AFRS with intracranial extension, gross erosion of the skull base or medial orbital wall and/or ophthalmic complications of AFRS, including visual loss. Acute bacterial or invasive fungal sinusitis and other non-AFRS sinus pathologies with orbital or skull base complications were excluded from the study. The mean age of patients was 22.7years. Proptosis was the most common presenting feature followed by diplopia and visual loss. Four patients exhibited unilateral visual loss with one case of sudden acute onset. Intracranial extradural spread to the middle cranial fossa was observed in two cases with cavernous sinus involvement, destruction of the entire cranial base and extension to the petrous temporal bone. Ten patients exhibited co-existing orbital and skull base erosion whereas gross erosion of the lamina papyracea alone was seen in one patient. All patients underwent endoscopic sinus surgery with complete disease clearance. The minimum and maximum follow-up periods were 1 and 3years, respectively with one documented recurrence 18months after surgery. Visual recovery was complete after sudden vision loss whereas it was only partial or absent in patients with prolonged vision loss. Cases of extensive AFRS with ophthalmic and skull base complications pose diagnostic and therapeutic challenges and merit early intervention with long-term follow-up.

The syrinx cavity with cranial extension in an adult patient with Chiari Type 1 malformation

The syrinx cavity with cranial extension in an adult patient with Chiari Type 1 malformation

Unusual congenital pulmonary anomaly with presumed left lung hypoplasia in a young dog

A seven-month-old, entire, male miniature schnauzer dog was referred with acute vomiting, inappetence and depression primarily as a result of a gastric foreign body (pine cones). During investigations, thoracic radiographs revealed increased volume of the right lung lobes, deviated cardiomediastinal structures and elevation of the heart from the sternum. Thoracic computed tomography revealed left cranial lung lobe hypoplasia and extension of the right cranial lung parenchyma across the midline to the left hemithorax. Branches of the right pulmonary vessels and bronchi also crossed the midline and extended to the left caudal lung lobe. These findings suggested that the right and left lungs were fused. In humans this finding is consistent with horseshoe lung, which is an uncommon congenital malformation. To the authors' knowledge, this case represents the first report of such a pulmonary anomaly in a dog.

Computed Tomography and Cross‐Sectional Anatomy of the Thorax of the Live Bottlenose Dolphin (Tursiops truncatus)

Pulmonary disease is one of the leading causes of cetacean morbidity and mortality in the wild and in managed collections. The purpose of this study was to present the computed tomographic (CT) appearance of the thorax of the live bottlenose dolphin (Tursiops truncatus) out-of-water and to describe the technical and logistical parameters involved in CT image acquisition in this species. Six thoracic CT evaluations of four conscious adult bottlenose dolphins were performed between April 2007 and May 2012. Animals were trained to slide out of the water onto foam pads and were transported in covered trucks to a human CT facility. Under light sedation, animals were secured in sternal recumbency for acquisition of CT data. Non-contrast helical images were obtained during an end-inspiratory breath hold. Diagnostic, high quality images were obtained in all cases. Respiratory motion was largely insignificant due to the species' apneustic respiratory pattern. CT findings characteristic of this species include the presence of a bronchus trachealis, absence of lung lobation, cranial cervical extension of the lung, lack of conspicuity of intrathoracic lymph nodes, and presence of retia mirabilia. Dorsoventral narrowing of the heart relative to the thorax was seen in all animals and is suspected to be an artifact of gravity loading. Diagnostic thoracic computed tomography of live cetaceans is feasible and likely to prove clinically valuable. A detailed series of cross-sectional reference images is provided.

Visualization of Craniofacial Development in the sox10: kaede Transgenic Zebrafish Line Using Time-lapse Confocal Microscopy

Vertebrate palatogenesis is a highly choreographed and complex developmental process, which involves migration of cranial neural crest (CNC) cells, convergence and extension of facial prominences, and maturation of the craniofacial skeleton. To study the contribution of the cranial neural crest to specific regions of the zebrafish palate a sox10: kaede transgenic zebrafish line was generated. Sox10 provides lineage restriction of the kaede reporter protein to the neural crest, thereby making the cell labeling a more precise process than traditional dye or reporter mRNA injection. Kaede is a photo-convertible protein that turns from green to red after photo activation and makes it possible to follow cells precisely. The sox10: kaede transgenic line was used to perform lineage analysis to delineate CNC cell populations that give rise to maxillary versus mandibular elements and illustrate homology of facial prominences to amniotes. This protocol describes the steps to generate a live time-lapse video of a sox10: kaede zebrafish embryo. Development of the ethmoid plate will serve as a practical example. This protocol can be applied to making a time-lapse confocal recording of any kaede or similar photoconvertible reporter protein in transgenic zebrafish. Furthermore, it can be used to capture not only normal, but also abnormal development of craniofacial structures in the zebrafish mutants.

Visualization of Craniofacial Development in the sox10: kaede Transgenic Zebrafish Line Using Time-lapse Confocal Microscopy

Vertebrate palatogenesis is a highly choreographed and complex developmental process, which involves migration of cranial neural crest (CNC) cells, convergence and extension of facial prominences, and maturation of the craniofacial skeleton. To study the contribution of the cranial neural crest to specific regions of the zebrafish palate a sox10: kaede transgenic zebrafish line was generated. Sox10 provides lineage restriction of the kaede reporter protein to the neural crest, thereby making the cell labeling a more precise process than traditional dye or reporter mRNA injection. Kaede is a photo-convertible protein that turns from green to red after photo activation and makes it possible to follow cells precisely. The sox10: kaede transgenic line was used to perform lineage analysis to delineate CNC cell populations that give rise to maxillary versus mandibular elements and illustrate homology of facial prominences to amniotes. This protocol describes the steps to generate a live time-lapse video of a sox10: kaede zebrafish embryo. Development of the ethmoid plate will serve as a practical example. This protocol can be applied to making a time-lapse confocal recording of any kaede or similar photoconvertible reporter protein in transgenic zebrafish. Furthermore, it can be used to capture not only normal, but also abnormal development of craniofacial structures in the zebrafish mutants.

Aspectos da morfologia radiográfica do esqueleto, tórax e abdome do quati (Nasua nasua Linnaeus, 1766)

Treze quatis (Nasua nasua) oriundos do Parque Zoológico da Universidade Federal do Mato Grosso foram contidos quimicamente e submetidos a diversos procedimentos radiográficos. Foram realizadas radiografias dos membros torácicos, membros pélvicos, tórax, abdome, pescoço e crânio. As imagens obtidas foram comparadas com peça anatômica e com imagens radiográficas de caninos. Foram realizadas descrições da morfologia radiográfica de vísceras e de estruturas esqueléticas e disponibilizadas imagens das principais projeções radiográficas da espécie. As principais diferenças entre a morfologia radiográfica dos membros de quatis e de caninos ficaram limitadas às mãos e aos pés. Os quatis apresentaram 5 dígitos bem desenvolvidos com os metacarpos e os metatarsos levemente mais curtos do que os dígitos correspondentes. Essa espécie apresentou 7 vértebras cervicais, 15 torácicas, 5 vértebras lombares e 3 sacrais (fusionadas). Os seios frontais mostraram-se mais amplos, com extensão cranial entre o osso maxilar e o nasal, e numerosos septos bem evidentes. A dentição observada foi I 3/3, C1/1, P4/4, M2/2 = 40 e as principais vísceras torácicas e abdominais apresentaram aspectos anatômico e radiográfico similares às descritas para caninos.

Requirement for frzb and fzd7a in cranial neural crest convergence and extension mechanisms during zebrafish palate and jaw morphogenesis

Regulation of convergence and extension by wnt-frizzled signaling is a common theme in embryogenesis. This study examines the functional requirements of frzb and fzd7a in convergence and extension mechanisms during craniofacial development. Using a morpholino knockdown approach, we found that frzb and fzd7a are dispensable for directed migration of the bilateral trabeculae, but necessary for the convergence and extension of the palatal elements, where the extension process is mediated by chondrocyte proliferation, morphologic change and intercalation. In contrast, frzb and fzd7a are required for convergence of the mandibular prominences, where knockdown of either frzb or fzd7a resulted in complete loss of lower jaw structures. Further, we found that bapx1 was specifically downregulated in the wnt9a/frzb/fzd7a morphants, while general neural crest markers were unaffected. In addition, expression of wnt9a and frzb was also absent in the edn−/− mutant. Notably, over-expression of bapx1 was sufficient to partially rescue mandibular elements in the wnt9a/frzb/fzd7a morphants, demonstrating genetic epistasis of bapx1 acting downstream of edn1 and wnt9a/frzb/fzd7a in lower jaw development. This study underscores the important role of wnt-frizzled signaling in convergence and extension in palate and craniofacial morphogenesis, distinct regulation of upper vs. lower jaw structures, and integration of wnt-frizzled with endothelin signaling to coordinate shaping of the facial form.

A giant mastoid cholesteatoma with posterior cranial extension causing mass effect and obstructive hydrocephalus

Cholesteatoma is a benign, keratinizing lesion with prolifertion of epithelial cells in the middle ear. Cholesteatomas are ivided into acquired and congenital (primary) subtypes. Acquired holesteatomas usually occur in the middle ear with rare extenion to the petroux apex unlike congenital cholesteatomas. These esions are postulated to be ectopic rests of embryologic epithelial issue in the petrous apex, which failed to undergo involution. As nternal desquamation occurs from the stratified squamous epitheium, keratinized debris accumulates centrally and forms a highly rganized structure. The advancing epithelium combined with host nflammatory response results in surrounding bone resorption [1]. he chronicity of this benign process may cause adjacent bone emodeling and mass effect without early clinical signs. We describe a rare case of giant mastoid cholesteatoma in an dult with consequent deleterious intracranial complications.

Massive Obstruction of Venous Return Due to a Primary Inferior Vena Cava Tumour

A 62-year-old patient was studied after an episode of fainting with oppressive pain that appeared and recurred during exercise. Abdominal-pelvic CT revealed a heterogeneous retroperitoneal mass from the infrarenal distal third of the inferior vena cava (IVC) with calcifications that was highly vascularized, partially extraand endoluminal, with cranial extension up to the right auricle, that was implanted in the septum and up to the tricuspid valve to the RV (Figs. 1 and 2). Given the obstruction of the IVC and the existence of collateral venous return, and considering the differential diagnosis between leiomyosarcoma and angiosarcoma with associated thrombosis, surgery was performed and the IVC was resected in 2 stages using laparotomy and sternotomy. Final pathology diagnosis: high-grade leiomyosarcoma. c i r e s p . 2 0 1 3 ; 9 1 ( 3 ) : e 1 7

Nasopharyngeal angiofibroma: A concise classification system and appropriate treatment options

ObjectivesTo describe a clear and simplified classification system for juvenile nasopharyngeal angiofibroma (JNA), and to describe suitable management options. Study designRetrospective medical record review. MethodsThe clinical and imaging materials of 51 cases of JNA diagnosed at our hospital between 1981 and 2011 were collected and studied. Based on our experiences, we prefer to divide JNAs into three types. Type I includes JNAs fundamentally localized to the nasal cavity, paranasal sinus, nasopharynx, or pterygopalatine fossa. Type II is a JNA extending into the infratemporal fossa, cheek region, or orbital cavity, with anterior and/or minimal middle cranial fossa extension but intact dura mater. Type III is a calabash-like massive tumor lobe in the middle cranial fossa. The management and prognosis for the three types of JNA were compared and evaluated. ResultsAmong cases of type I JNA (n=16), the entire mass was removed by the initial operation in 15 cases and by a repeat operation in 1 case. Among cases of type II JNA (n=29), the entire mass was removed by the first operation in 24 cases and by repeat operation in 5 cases. In cases of type III JNA (n=6), the huge calabash-like lobe in the middle cranial fossa could not be completely excised; 4 cases underwent radiotherapy and 2 cases were lost to follow-up. Conclusions1) The transnasal cavity approach with endoscopic guidance is suitable for type I JNA resection. 2) The transantral–infratemporal fossa–nasal cavity combined approach is reliable for resection of a type II JNA, which extends into the deep anterior cranial fossa and/or minimally into the middle cranial fossa, with intact dura mater. 3) The complete removal of a type III JNA is difficult, even through a combined extracranial and intracranial approach. Radiotherapy is useful for treating the residual intracranial tumor. The successful or failed experiences of 6 typical cases prove that this revised classification system is reasonable and reliable.

Posterior fossa meningioma "our experience" in 64 cases

Background:Posterior fossa meningiomas are 20% of all intracranial meningiomas. These are slow-growing tumors thus become large before presentation. Microsurgical resection is the treatment of choice for the majority of these lesions, but variable locations, large size at diagnosis, frequent encroachment of neural and vascular structures, and their potentially invasive behavior are some of the features of these tumors that make their resection challenging.Materials and Methods:We studied 64 cases of posterior fossa meningioma operated in last 6 years, and analysed the technical difficulties encountered during excision of these tumors. Postoperative complications and outcomes of these patients were also analysed.Results:Gross total excision was achieved in 72% cases. Partial excision or subtotal excision was more in petroclival, jugular foramen with extra cranial extension, tentorial with intrasinus extension and ventral foramen magnum. Postoperative complication in form of new or aggravation of existing neurological deficit was found in 33% cases and CSF leak in 12.5% cases. We encountered the recurrence of total 10 cases (16%) over mean follow-up of 4 years. Most of the recurrent cases were seen in petroclival and tentorial subgroups with partial or subtotal excision.Conclusion:Posterior fossa meningiomas are difficult to excise due to close relation to cranial nerves and vessels. Use of microscope, CUSA, intraoperative nerve monitor help in removal and preserving surrounding important anatomical structures. Although neurological deterioration is common postoperatively, recovery does occur completely after total removal thus increasing the recurrence free period and improving the outcome.

Fourniers gangrene-A case report and literature review

Fournier’s gangrene(FG) is a rare, necrotising fasciitis of the genitals and perineum with occasional cranial extension to the abdominal wall caused by a mixture of aerobic and anaerobic microorganisms. The complications of this synergistic infection are multiple organ failure and death. Due to the aggressive nature of this condition, early diagnosis is crucial. Treatment involves extensive soft tissue debridement and broad-spectrum antibiotics. Despite appropriate therapy, mortality is high. We report a case of a gentleman who presented with gangrenous and necrotic penile, scrotal and perineal areas. Patient was successfully managed by extensive soft tissue debridement, broad spectrum antibiotics and skin grafting. DOI: http://dx.doi.org/10.3126/jcmsn.v7i3.6713 Journal of College of Medical Sciences-Nepal, 2011, Vol-7, No-3, 62-67