Intradural Surgery Research Articles

A New Classification for Pathologies of Spinal Meninges-Part 2: Primary and Secondary Intradural Arachnoid Cysts.

Spinal intradural arachnoid cysts are rare causes of radiculopathy or myelopathy. Treatment options include resection, fenestration, or cyst drainage. To classify intradural spinal arachnoid cysts and present results of their treatment. Among 1519 patients with spinal space occupying lesions, 130 patients demonstrated intradural arachnoid cysts. Neuroradiological and surgical features were reviewed and clinical data analyzed. Twenty-one patients presented arachnoid cysts as a result of an inflammatory leptomeningeal reaction related to meningitis, subarachnoid hemorrhage, intrathecal injections, intradural surgery, or trauma, ie, secondary cysts. For the remaining 109 patients, no such history could be elucidated, ie, primary cysts. Forty-six percent of primary and 86% of secondary cysts were associated with syringomyelia. Patients presented after an average history of 53 ± 88 months. There were 122 thoracic and 7 lumbar cysts plus 1 cervical cyst. Fifty-nine patients with primary and 15 patients with secondary cysts underwent laminotomies with complete or partial cyst resection and duraplasty. Mean follow-up was 57 ± 52 months. In the first postoperative year, profound improvements for primary cysts were noted, in contrast to marginal changes for secondary cysts. Progression-free survival for 10 years following surgery was determined as 83% for primary compared to 15% for secondary cysts. Despite differences in clinical presentation, progression-free survival was almost identical for patients with or without syringomyelia. Complete or partial resection leads to favorable short- and long-term results for primary arachnoid cysts. For secondary cysts, surgery can only provide clinical stabilization for a limited time due to the often extensive arachnoiditis.

Cervical arachnoid cyst mimicking the cause of cervical radiculopathy: A case report

Abstract We herein present a case involving an asymptomatic cervical intradural arachnoid cyst that was suspected to be the cause of the patient's radicular pain. Magnetic resonance imaging showed a small, round intradural mass beside the cervical nerve root. An arachnoid cyst of this shape has not been previously reported. Intraoperative examination revealed that the cyst was not compressing the nerve root and was asymptomatic. Intradural spinal surgery is sometimes associated with serious complications. The knowledge that arachnoid cysts of this shape are asymptomatic can help to avoid unnecessary surgery.

The use of a novel perfusion-based cadaveric simulation model with cerebrospinal fluid reconstitution comparing dural repair techniques: a pilot study

Background ContextWatertight dural repair is crucial for both incidental durotomy and closure after intradural surgery. PurposeThe study aimed to describe a perfusion-based cadaveric simulation model with cerebrospinal fluid (CSF) reconstitution and to compare spine dural repair techniques. Study Design/SettingThe study is set in a fresh tissue dissection laboratory. Sample SizeThe sample includes eight fresh human cadavers. Outcome MeasuresA watertight closure was achieved when pressurized saline up to 40 mm Hg did not cause further CSF leakage beyond the suture lines. MethodsFresh human cadaveric specimens underwent cannulation of the intradural cervical spine for intrathecal reconstitution of the CSF system. The cervicothoracic dura was then exposed from C7–T12 via laminectomy. The entire dura was then opened in six cadavers (ALLSPINE) and closed with 6-0 Prolene (n=3) or 4-0 Nurolon (n=3), and pressurized with saline via a perfusion system to 60 mm Hg to check for leakage. In two cadavers (INCISION), six separate 2-cm incisions were made and closed with either 6-0 Prolene or 4-0 Nurolon, and then pressurized. A hydrogel sealant was then added and the closure was pressurized again to check for further leakage. ResultsSpinal laminectomy with repair of intentional durotomy was successfully performed in eight cadavers. The operative microscope was used in all cases, and the model provided a realistic experience of spinal durotomy repair. For ALLSPINE cadavers (mean: 240 mm dura/cadaver repaired), the mean pressure threshold for CSF leakage was observed at 66.7 (±2.9) mm Hg in the 6-0 Prolene group and at 43.3 (±14.4) mm Hg in the 4-0 Nurolon group (p>.05). For INCISION cadavers, the mean pressure threshold for CSF leakage without hydrogel sealant was significantly higher in 6-0 Prolene group than in the 4-0 Nurolon group (6-0 Prolene: 80.0±4.5 mm Hg vs. 4-0 Nurolon: 32.5±2.7 mm Hg; p<.01). The mean pressure threshold for CSF leakage with the hydrogel sealants was not significantly different (6-0 Prolene: 100.0±0.0 mm Hg vs. 4-0 Nurolon: 70.0±33.1 mm Hg). The use of a hydrogel sealant significantly increased the pressure thresholds for possible CSF leakage in both the 6-0 Prolene group (p=.01) and the 4-0 Nurolon group (p<.01) when compared with mean pressures without the hydrogel sealant. ConclusionsWe described the feasibility of using a novel cadaveric model for both the study and training of watertight dural closure techniques. 6-0 Prolene was observed to be superior to 4-0 Nurolon for watertight dural closure without a hydrogel sealant. The use of a hydrogel sealant significantly improved watertight dural closures for both 6-0 Prolene and 4-0 Nurolon groups in the cadaveric model.

Rapid Progression of Extensive Arachnoid Adhesion Longer Than Twelve Segments and Cysts Formation after Posterior Lumbar Interbody Fusion: Case Report

Arachnoid cysts and intradural adhesion are uncommon in postoperative complication rather than congenital condition. The adhesion and cysts are usually around surgical site but some extend to a distant place. The authors report a case of formation of arachnoid cysts and adhesion far away from original surgical site with signifi cant clinical manifestations after posterior lumbar interbody fusion (PLIF).A 55-year-old woman accepted PLIF and got a good recovery but her dura mater was torn and sutured during procedure. Six months after her 1st surgery, she felt rapid progressing numbness from foot to belly and weakness of both lower limbs. On Examination bilateral deep tendon refl exes were hyperactive. Magnetic resonance imaging (MRI) showed intradural adhesion formed from T4 to sacral canal. Cerebrospinal fluid terminated at T4 level and there exactly the arachnoid cyst was formed. The long intradural adhesion and distant cyst formation made this case unique and the cause of neurological manifestations. Then the patient underwent intradural exploratory surgery and cyst-abdominal shunting. The cyst was actually found to be the terminal part of remaining subarachnoid space. Patient’s numbness stopped advancing upward and the strength of both lower limbs gradually improved after surgery. Therefore, arachnoid cyst and adhesion might appear at any place after spine surgery with dural rupture. Exploratory surgery and timely decompression can effectively slow down the progression of disease.Spinal meningeal cysts are rare and have been described as “arachnoid cysts,” “pouches”, or “diverticula”.7 Most spinal intradural arachnoid cysts are thought to be congenital but still some acquired arachnoid cysts were reported as to be the results of trauma, hemorrhage or infection.8 Even fewer were caused by intradural infl ammation after invasive diagnostic test and treatment. Nepal Journal of Neuroscience. Vol. 13, No. 2, 2016, Page: 94-98

351 Do Rehabilitation Therapies Affect Patient Outcomes After Chiari I Decompression Surgery?

Chiari I decompression (C1D) is a common pediatric neurosurgical procedure. Inpatient C1D postoperative care is often notable for pain and poor activity. Initiation of rehabilitation therapies, including physical, occupational, massage, and recreational, may impact recovery, but published evidence is scant.An electronic medical record query by Current Procedural Terminology code identified all patients who underwent C1D at our pediatric tertiary-care hospital from January 1, 2012 through February 20, 2016. Chiari II, redo C1D, and unrelated foramen magnum decompression operations were excluded. Demographic, financial, surgical, therapy, and outcome data were analyzed.The study population included 59 patients with a mean age of 11 years (range 1-18) and sex distribution of 56% male. Sixty-one percent (36/59) had private insurance and 39% (23/59) had public insurance. C1D was intradural in 75% (44/59) and extradural in 25% (15/59). Seventy-three percent of patients (43/59) received at least 1 form of rehabilitation therapy. Public insurance was associated with a higher reoperation and readmission rate than private insurance. Intradural surgery was associated with a greater LOS, reoperation rate, and readmission rate than extradural surgery. Having received any rehabilitation therapy was associated with an increased LOS compared with no therapy, even when stratified for intradural vs extradural surgery, but a lower readmission rate. An association of therapy with reoperation rate was less distinct.In our population, rehabilitation therapy was associated with an increased inpatient LOS but a lower readmission rate. It is possible that the initiation of therapy was a marker for a more symptomatic child who would require more time to recover. It is also possible that the lower readmission rate related to an increased discharge readiness among the therapy group. Further investigation is ongoing.

Novel Concepts in Spine Pathophysiology.

Tethered cord syndrome (TCS) occurs as a constellation of neurologic signs and symptoms resulting from longitudinal traction on the spinal cord between fixed points. This condition involves a tug-of-war between ascent and inhibition of ascent of intrathecal nervous tissue within the vertebral canal during growth. Causes include thickened filum terminale, myelomeningocele, split cord malformation, and previous intradural surgery. Patients report low back, lower extremity, and perineal pain; lower extremity sensory and motor deficits; urinary and bowel incontinence; and sexual dysfunction. When not treated early or adequately, TCS can lead to neurologic devastation.

The anaesthetist’s SonoSite Probe – Successful adjunct to complex intradural spinal surgery or poor man’s intraoperative ultrasound?

The use of expensive, sophisticated, intraoperative ultrasound systems is established in cranial neurosurgery and less so in the realms of intradural spine. For units yet to acquire such costly devices, we demonstrate our experience of the readily available, anaesthetist’s SonoSite™ probe in intradural spinal surgery.

The Use Fibrin Sealant after Spinal Intradural Tumor Surgery: Is It Necessary?

ObjectiveA fibrin sealant is commonly applied after closure of an incidental or intended durotomy to reduce the complications associated with the leakage of cerebrospinal fluid. Routine usage might not be essential after closure of an intended durotomy, which has clear cut-margins. We investigated the efficacy of fibrin sealants for primary intradural spinal cord tumor surgery.MethodsA retrospective review was performed for 231 consecutive surgically treated patients with primary intradural spinal cord tumors without extradural extension. Fibrin sealants were not used for 47 patients (group I: age, 51.57±16.75 years) and were applied to 184 patients (group II: age, 48.8±14.7 years). The surgical procedures were identical except for the use of a fibrin sealant after closure of the durotomy. The primary outcome was the occurrence of complications (wound problems, hematoma collection, infection, and neurological deterioration). The covariates were age, sex, body mass index, operation time, pre-/postoperative ambulation, number of laminectomies, and type of tumor.ResultsSchwannoma was the most common pathology (n=134), followed by meningioma (n=35) and ependymoma (n=31). Complications occurred in 13 patients (3 in group I and 10 in group II, p=0.73). The postoperative ambulation status (p<0.01; odds ratio, 28.8; 95% confidence interval, 6.9-120.0) and operation time (p=0.04; cutoff, 229 minutes; sensitivity, 62%; specificity, 72%) were significant factors, whereas the use of a fibrin glue was not (p=0.47).ConclusionThe use of a fibrin sealant might not be essential to reduce complications after surgery for primary spinal intradural tumor.

What is the risk of a shunt malfunction after elective intradural surgery?

Surgery for CSF diversion is the most common procedure performed by pediatric neurosurgeons. The failure rates for shunts remain frustratingly high, resulting in a burden to patients, families, providers, and healthcare systems. The goal of this study was to quantify the risk of a shunt malfunction in patients with an existing shunt who undergo an elective intradural operation. All elective intradural surgeries (cranial and spinal) at Le Bonheur Children's Hospital from January 2010 through June 2014 were reviewed to identify those patients who had a functional ventricular shunt at the time of surgery. Patient records were reviewed to collect demographic, surgical, clinical, radiological, and pathologic data, including all details related to any subsequent shunt revision surgery. The primary outcome was all-cause shunt revision (i.e., malfunction or infection) within 90 days of elective intradural surgery. One hundred and fifty elective intradural surgeries were identified in 109 patients during the study period. There were 14 patients (12.8%, 13 male) who experienced 16 shunt malfunctions (10.7%) within 90 days of elective intradural surgery. These 14 patients underwent 13 craniotomies, 2 endoscopic fenestrations for loculated hydrocephalus, and 1 laminectomy for dorsal rhizotomy. Median time to failure was 9 days, with the shunts in half of our patients failing within 5 postoperative days. Those patients with failed shunts were younger (median 4.2 years [range 0.33-26 years] vs median 10 years [range 0.58-34 years]), had a shorter time interval from their previous shunt surgery (median 11 months [range 0-81 months] vs median 20 months [range 0-238 months]), and were more likely to have had intraventricular surgery (80.0% vs. 60.3%). This is the first study to quantify the risk of a shunt malfunction after elective intradural surgery. The 90-day all-cause shunt failure rate (per procedure) was 10.7%, with half of the failures occurring within the first 5 postoperative days. Possible risk factors for shunt malfunction after elective intradural surgeries are intraventricular surgical approach, shorter time since last shunt-related surgery, and young age.

191 What Is the Risk of a Shunt Malfunction After Elective Intradural Surgery?

191 What Is the Risk of a Shunt Malfunction After Elective Intradural Surgery?

Management of postoperative pseudomeningoceles: an international survey study.

Pseudomeningoceles are common complications after posterior fossa and intradural spinal surgery and are often asymptomatic. Management guidelines are lacking, and anecdotally, we have encountered radically different suggested treatments varying from observation to immediate surgical intervention. The goal of this study was to determine the prevailing opinions among neurosurgeons on the management of this condition. Neurosurgeons from around the world were invited via an International Society for Pediatric Neurosurgery (ISPN) and Neurosurgery ListServ e-blast to participate in a 33-question survey on the management of pseudomeningoceles, presented as simulated scenarios after posterior fossa and spinal intradural surgery. Two hundred forty-one responses were obtained. Pseudomeningoceles after posterior fossa tumor resection, in the absence of hydrocephalus, were typically managed nonoperatively for 7 to 14days before re-exploration. Only 0.5% of the surgeons would offer upfront repair of the pseudomeningocele. In the presence of hydrocephalus, 48% of the neurosurgeons intervene initially with cerebrospinal fluid (CSF) diversion and would change therapy if the lesion did not resolve in 2 to 4days. Ninety percent of the surgeons manage spinal pseudomeningoceles nonoperatively for 7-14days before re-exploration is considered. The most common steps taken to prevent pseudomeningoceles are watertight closure, tissue glues, and duroplasty. The present zeitgeist suggests that, in the absence of hydrocephalus, initial observation is appropriate for cranial and spinal pseudomeningoceles. Operative revision should be reserved for failure of conservative treatment. If hydrocephalus is present, consideration should be made for CSF diversion. This study may serve as a guideline regarding acceptable management.

Normal Cerebellar Metabolism in a Patient with Superficial Siderosis

Normal Cerebellar Metabolism in a Patient with Superficial Siderosis

Intraoperative recording of the bulbocavernosus reflex.

: The bulbocavernosus reflex (BCR) is mediated by the sacral somatic afferent/efferent periphery as well as the sacral cord. Unfortunately, the reflex has suffered from a partly deserved reputation as difficult to implement. However, recent stratagems have improved the test's reliability. Multipulse stimulation (enhanced by double trains as required) and exacting recording technique can yield positive and remarkably reproducible results in patients of all ages and either sex. In this review, we document a 94% baseline BCR acquisition rate among 100 consecutive cases in one institution. Acceptance and routine use of the BCR is needed to help assure optimal post-operative low sacral function in intradural and extradural surgeries at the level of conus medullaris, cauda equina, sacral plexus, and the pudendal nerve. Case studies within this review illustrate the power of the BCR to predict patient outcome or, much more importantly, reverse incipient patient injury in real time.

Management of intended durotomy in minimally invasive intradural spine surgery: clinical article.

Minimally invasive surgery (MIS) has been increasingly used for the treatment of various intradural spinal pathologies in recent years. Although MIS techniques allow for successful treatment of intradural pathology, primary dural closure in MIS can be technically challenging due to a limited surgical corridor through the tubular retractor system. The authors describe their experience with 23 consecutive patients from a single institution who underwent MIS for intradural pathologies, along with a review of pertinent literature. A retrospective review of a prospectively collected surgical database was performed to identify patients who underwent MIS for intradural spinal pathologies between November 2006 and July 2013. Patient demographics, preoperative records, operative notes, and postoperative records were reviewed. Primary outcomes include operative duration, estimated blood loss, length of bed rest, length of hospital stay, and postoperative complications, which were recorded prospectively. Twenty-three patients who had undergone MIS for intradural spinal pathologies during the study period were identified. Fifteen patients (65.2%) were female and 8 (34.8%) were male. The mean age at surgery was 54.4 years (range 30-74 years). Surgical pathologies included neoplastic (17 patients), congenital (3 patients), vascular (2 patients), and degenerative (1 patient). The most common spinal region treated was lumbar (11 patients), followed by thoracic (9 patients), cervical (2 patients), and sacral (1 patient). The mean operative time was 161.1 minutes, and the mean estimated blood loss was 107.2 ml. All patients were allowed full activity less than 24 hours after surgery. The median length of stay was 78.2 hours. Primary sutured dural closure was achieved using specialized MIS instruments with adjuvant fibrin sealant in all cases. The rate of postoperative headache, nausea, vomiting, and diplopia was 0%. No case of cutaneous CSF fistula or symptomatic pseudomeningocele was identified at follow-up, and no patient required revision surgery. Primary dural closure with early mobilization is an effective strategy with excellent clinical outcomes in the use of MIS techniques for intradural spinal pathology. Prolonged bed rest after successful primary dural closure appears unnecessary, and the need for watertight dural closure should not prevent the use of MIS techniques in this specific patient population.

S100B, intraoperative neuromonitoring findings and their relation to clinical outcome in surgically treated intradural spinal lesions

Neurophysiological monitoring (IOM) consisting of somatosensory (SEPs), muscle (MEPs) and spinal motor evoked (D-wave; spinal MEPs) potentials is used to indicate injury related to surgical treatment of intradural and intramedullary lesions. Combining spinal and muscle MEPs reliably predicts long-term motor deficit. If spinal MEPs recording is not possible, additional markers-e.g. S100B, a serum marker for glial injury-may be a helpful adjunct. Thus, serial serum S100B measurements were related to both the intraoperative IOM recordings and the long-term neurological outcome in patients surgically treated for cervical and thoracic intradural lesions. In 33 patients (9 men, 24 women, 54 ± 17 years) during intramedullary (8) or intradural (25) cervical or thoracic spinal surgeries significant intraoperative SEP-amplitude decrement >50 % or MEP loss and serial S100B serum concentration (perioperative days 0, 1-3, 5) were related to outcome (>1 year after discharge, grouped into improved and unchanged/altered neurological symptoms). Differences in S100B levels between patients with improved and unchanged/altered neurological outcome were significantly on postoperative days 2 (0.085 ± 0.08 μg/l vs 0.206 ± 0.07 μg/l, p = 0.005) and 3 (0.076 ± 0.03 μg/l vs 0.12 ± 0.05 μg/l, p = 0.007). All patients with permanent altered neurological symptoms developed S100B levels >0.08 μg/l (0.09-0.35 μg/l). Eighty-one percent of patients with improved neurological symptoms presented with S100B levels ≤0.08 μg/l (0.02-0.08 μg/l). Nine out of ten patients (90 %) without changes in EP and S100B had an improved long-term outcome, whereas 9/13 patients (69 %) with changes in EP and S100B had altered neurological symptoms in long-term outcome. Intraoperative stable EPs and S100B ≤0.08 μg/l may be used as a marker to predict long-term neurological improvement, whereas EP-changes and elevated S100B levels on the 3rd postoperative day may be useful as a marker to predict long-term neurological alteration. In summary, the combined use of S100B and EPs might be helpful in the prediction of the severity of adverse spinal cord affection following surgery and guidance of patients.

Supratentorial Intraparenchymal Haemorrhages during Spine Surgery

Intracranial haemorrhages are rare but potentially life-threatening complications of spine surgery. Most reported cases involved subdural or cerebellar haemorrhages; supratentorial parenchymal bleeding is very uncommon. We report a 28-year-old woman who underwent resection of a thoracic Ewing's sarcoma, and developed fatal haemorrhages around her cerebral metastases during surgery. The clinical presentations, possible pathogenesis and potential preventive measures are discussed. Patients with disseminated metastases within the neural axis are at risks of intracranial complications during spine surgery. The presence of intracranial mass lesions should be considered as a relative contraindication to intradural spine surgery.

The value of neuromonitoring in cervical spine surgery.

Dear Editor, We read with interest the paper by Epstein entitled: The need to add motor evoked potential monitoring to somatosensory and electromyographic monitoring in cervical spine surgery.[1] The paper reviews the spine surgery literature regarding the use of intraoperative neural monitoring (IONM). Theoretically, IONM should alert the operative team that impending neurological injury is possible and a corrective maneuver performed to prevent such. IONM may be problematic in that it might alarm and result in an abandonment or alteration of the surgical procedure when no true neurological deficit is subsequently demonstrated (false positive). More worrisome, however, is the situation when no alert is observed and neurological injury ensued (false negative). Debate may be held with regard to the most appropriate surgical procedures for the use of IONM. Ideally, this should involve procedures in which potentially harmful maneuvers can be reversed. A classic example is deformity correction, which can be reversed if IONM suggests such. In cases in which “surgical reversal” is not possible, IONM has been shown to demonstrate true and false positives, however, studies have not demonstrated improved outcomes.[7] Many infer that IONM is associated with improved clinical results. However, it should be noted that the referenced studies compared outcomes with historical cohorts. Epstein et al.[2] reported 100 cases of IONM monitored cervical surgeries with no new neurological deficit. The historical cohort of this study included 218 patients operated in years 1985-1989, 8 of which became quadriplegic. This control population is clearly an outlier, as quadriplegia following elective cervical spine surgery for degenerative conditions is, indeed, a rarity and the rate is far less than the nearly 4% reported in the referenced study. Other studies cited by Epstein[1] show a high rate of false positives or false negatives with IONM, and low rate of true positives.[3,5,6] During degenerative cervical spine surgery, neurological injury may occur any of several phases. It may occur during induction of anesthesia with resultant hypotension, during positioning (flexion or extension) of the cervical spine in either prone or supine position, from intraoperative hypotension, and/or from direct surgical trauma. With the exception of hypotension and positioning, none of these potential causes of neurological injury are reversible. IONM, therefore can only signal that a neurological injury may have occurred, but does not afford the surgeon an enhanced opportunity to remedy or mitigate the neurological injury. When spinal cord injury occurs from direct surgical trauma, IONM serves only to document the timing of the trauma and cannot assist with altering the clinical outcome. There may then be little utility for IONM in degenerative cervical spine surgery. This conclusion has been borne out in the literature. Resnick et al.[7] reviewed the literature regarding IONM for degenerative cervical spine surgery. Their published guidelines concluded that relying on IONM changes as an indication for altering surgical procedure or administration of steroids has not been shown to reduce the incidence of neurological deterioration. The addition of IONM to degenerative cervical surgery has financial implications, however, cost-benefit analysis has not demonstrated benefit.[4] IONM is also often used for medico-legal reasons. Epstein reviewed the cervical spine surgery verdicts and determined the causes for verdicts were negligent surgery, lack of informed consent, failure to diagnose/treat, and failure to brace. She speculated that failure to adequately perform IONM may become the fifth reason for verdicts in cervical spine surgery. As the guidelines for cervical spinal surgery do not include the use of IONM,[7] and no clear algorithm for intraoperative action when IONM changes are observed, the routine use of IONM cannot serve as protection against a plaintiffs’ verdict. In the authors’ opinion, IONM in spine surgery has a definite role. This role includes intradural tumor surgery, deformity surgery, and cases in which patient positioning in and of itself poses neurological risk. IONM, however, has not been proven effective as a neuroprotective maneuver in the majority of cervical degenerative surgical procedures.

Back pain in patients with degenerative spine disease and intradural spinal tumor: what to treat? when to treat?

Back pain is common in industrialized countries and one of the most frequent causes of work incapacity. Successful treatment is, therefore, not only important for improving the symptoms and the quality of life of these patients but also for socioeconomic reasons. Back pain is frequently caused by degenerative spine disease. Intradural spinal tumors are rare with an annual incidence of 2-4/1,00,000 and are mostly associated with neurological deficits and radicular and nocturnal pain. Back pain is not commonly described as a concomitant symptom, such that in patients with both a tumor and degenerative spine disease, any back pain is typically attributed to the degeneration rather than the tumor. The aim of the present retrospective investigation was to study and analyze the impact of microsurgery on back/neck pain in patients with intradural spinal tumor in the presence of degenerative spinal disease in adjacent spinal segments. Fifty-eight consecutive patients underwent microsurgical, intradural tumor surgery using a standardized protocol assisted by multimodal intraoperative neuromonitoring. Clinical symptoms, complications and surgery characteristics were documented. Standardized questionnaires were used to measure outcome from the surgeon's and the patient's perspectives (Spine Tango Registry and Core Outcome Measures Index). Follow-up included clinical and neuroradiological examinations 6 weeks, 3 months and 1 year postoperatively. Back/neck pain as a leading symptom and coexisting degenerative spine disease was present in 27/58 (47 %) of the tumor patients, and these comprised to group under study. Patients underwent tumor surgery only, without addressing the degenerative spinal disease. Remission rate after tumor removal was 85 %. There were no major surgical complications. Back/neck pain as the leading symptom was eradicated in 67 % of patients. There were 7 % of patients who required further invasive therapy for their degenerative spinal disease. Intradural spinal tumor surgery improves back/neck pain in patients with coexisting severe degenerative spinal disease. Intradural spinal tumors seem to be the only cause of back/neck pain more often than appreciated. In these patients suffering from both pathologies, there is a higher risk of surgical overtreatment than undertreatment. Therefore, elaborate clinical and radiological examinations should be performed preoperatively and the indication for stabilization/fusion should be discussed carefully in patients foreseen for first time intradural tumor surgery.

CSF complications following intradural spinal surgeries in children

Cerebrospinal fluid (CSF) leakage is a complication of intradural spinal surgery and is associated with poor wound healing and infection. The incidence of CSF leak is reported at ∼16% in adults, but little information is available in children. The aim of this study is to determine the CSF leak rate and predisposing factors after intradural pediatric spinal surgeries. This study was a retrospective chart review of 638 intradural spinal operations at BC Children's Hospital. CSF leak was defined as pseudomeningocele or CSF leak through incision. Primary operations to untether lipomyelomeningoceles, myelomeningocele/meningocele closure, and Chiari decompressions were excluded. CSF leaks occurred in 7.1%, with 3% having overt CSF leaks through skin (OCSF leak). CSF leaks, specifically OCSF leaks, were associated with postoperative wound infection (P = 0.0016). Sixteen of 45 cases of CSF leak required reoperation. The type of dural suture used, site of operation, or use of fibrin glue did not affect CSF leak rates. Previous spinal surgery (P < 0.0001), use of dural graft (P = 0.0043), method of dural suturing (P = 0.0023), and procedure performed (P < 0.001) were associated with postoperative CSF leakage. Patients with CSF leak were older than those without leak (98 vs. 72 months, P = 0.002). Our results provide evidence on intraoperative factors that may predispose to CSF leaks after spinal intradural surgery and may help guide surgical practice. This study confirms that the pediatric population shares many of the same risk factors for CSF leak as in adult populations. Further research is needed to explain how specific factors are associated with CSF leaks.

Dural closure for the treatment of superficial siderosis

Superficial siderosis (SS) of the CNS is a rare disease caused by repeated hemorrhages in the subarachnoid space. The subsequent deposition of hemosiderin in the brain and spinal cord leads to the progression of neurological deficits. The causes of bleeding include prior intradural surgery, carcinoma, arteriovenous malformation, nerve root avulsion, and dural abnormality. Recently, surgical treatment of SS associated with dural defect has been reported. The authors of the present report describe 2 surgically treated SS cases and review the literature on surgically treated SS. The patients had dural defects with fluid-filled collections in the spinal canal. In both cases, the dural defects were successfully closed, and the fluid collection was resolved postoperatively. In one case, the neurological symptoms did not progress postoperatively. In the other case, the patient had long history of SS, and the clinical manifestations partially deteriorated after surgery, despite the successful dural closure. In previously reported surgically treated cases, the dural defects were closed by sutures, patches, fibrin glue, or muscle/fat grafting. Regardless of the closing method, dural defect closure has been shown to stop CSF leakage and subarachnoid hemorrhaging. Successfully repairing the defect can halt the disease progression in most cases and may improve the symptoms that are associated with CSF hypovolemia. However, the effect of the dural closure may be limited in patients with long histories of SS because of the irreversibility of the neural tissue damage caused by hemosiderin deposition. In patients with SS, it is important to diagnose and repair the dural defect early to minimize the neurological impairments that are associated with dural defects.