Progressive Herniation Research Articles

Evaluation of laparoscopic versus open sacrocolpopexy for vaginal vault prolapse – A study from a tertiary care center

Background: Post hysterectomy vault prolapse is a progressive herniation of the vaginal vault through the urogenital diaphragm and commonly leads to per vaginal bulge. Surgically, vault prolapse is corrected by sacrocolpopexy which can be done both as an open abdominal surgery and as a laparoscopic repair. Aims and Objectives: This study was performed to compare the therapeutic efficacies of laparoscopic and abdominal sacrocolpopexy. Materials and Methods: This study includes 50 cases of vault prolapsed who underwent hysterectomy previously, admitted in our institution and operated during January 2021–June 2022 for a period of 18 months with both open abdominal and laparoscopic sacrocolpopexy. We compared the basic characteristics, duration of surgery, post-operative stay, post-operative complications, and patient satisfaction between open and laparoscopic groups. Results: No significant difference was observed between the characteristics of the patients in the abdominal-approach group and the laparoscopic-approach group. The laparoscopic-approach group had a lower intraoperative estimated blood loss (187.8 vs. 90.3 mL, P<0.001) and a shorter operative time (148.0 vs. 115.3 min, P<0.001) than the abdominal-approach group. The complication rates of the two groups were not significantly different. Conclusion: Our Study is favorable for the use of laparoscopic approach over open abdominal surgery for treating cases of vault prolapse for sacrocolpopexy. The less invasive method leads to less blood loss and a shorter operative time than an open approach.

Natural history of posterior fetal cephaloceles and incidence of progressive cephalocele herniation.

In utero repair of fetal posterior cephaloceles (meningocele and encephalocele) is being performed based on the premise that fetal surgery prevents progressive herniation of neural tissue and brain damage during pregnancy. However, the extent to which progressive herniation occurs during pregnancy, specifically from prenatal diagnosis to after delivery, is not well known. The objective of this study was to describe the natural history of patients with fetal cephaloceles focusing on the incidence of progressive herniation. The authors conducted a retrospective cohort study of all patients referred to their center for posterior fetal cephalocele between 2006 and 2021. All patients underwent prenatal and postnatal MRI. Progressive herniation (primary outcome) was defined as an increase in the absolute volume of neural tissue within the cephalocele of > 5% or new herniation of a critical structure into the cephalocele. Total brain and cephalocele volumes were calculated to determine herniation progression from prenatal to postnatal MRI. Information on the presence of hydrocephalus, epilepsy, and developmental delay (secondary outcomes) was collected at 1 year of age. Twenty patients met all study criteria. Ten patients (50%; 95% CI 0.27-0.73) demonstrated progressive herniation from prenatal to postnatal MRI. Three patients with progressive herniation were diagnosed with a meningocele prenatally and had an encephalocele postnatally. Two patients without progression had meningocele identified prenatally that regressed and became atretic by birth. Both prenatal hindbrain herniation (p = 0.03) and prenatal microcephaly (p = 0.05) were predictive of progressive herniation. The rates of hydrocephalus (44%), epilepsy (44%), and developmental delay (63%) were not associated with the occurrence of progressive herniation in this study. In this study, progressive herniation was not a rare event (50%). Fetal hindbrain herniation and fetal microcephaly were associated with the occurrence of progressive herniation. These results support further investigations into why progressive herniation occurs in utero and if progressive cerebral herniation in utero plays a significant role in determining clinical outcome.

Laparoscopic sacrocolpopexy versus open abdominal sacrocolpopexy for pelvic organ prolapse repair: A retrospective cohort study

IntroductionPelvic organ prolapse (POP) is a progressive herniation of the pelvic organs through the urogenital diaphragm and commonly leads to vaginal bulge. Sacrocolpopexy is a procedure that surgically corrects POP and can be performed as open abdominal surgery or laparoscopic surgery. This study was performed to compare the therapeutic efficacies of laparoscopic and abdominal sacrocolpopexy with hysterectomy. MethodsThe medical records of 105 patients who had undergone laparoscopic or open abdominal sacrocolpopexy with hysterectomy at Jeju National University Hospital were retrospectively reviewed. We compared the basic characteristics and clinical outcomes of these two groups of patients. ResultsNo significant difference was observed between the characteristics of the patients in the abdominal-approach group and the laparoscopic-approach group. The laparoscopic-approach group had a lower intraoperative estimated blood loss (177.8 vs. 89.3 mL, P < 0.001) and a shorter operative time (132.0 vs. 112.3 min, P < 0.001) than the abdominal-approach group. The complication rates of the two groups were not significantly different. ConclusionThe results of our study favor the use of a laparoscopic approach for sacrocolpopexy with hysterectomy. The less invasive method leads to less blood loss and a shorter operative time than an open approach, while maintaining a comparable rate of complications.

Long-term course of anterior spinal cord herniation presenting with an upper motor neuron syndrome: case report illustrating diagnostic and therapeutic implications

BackgroundAnterior spinal cord herniation (aSCH) is a rare cause of myelopathy which may present as pure motor syndrome and mimic other degenerative diseases of the spinal cord. In slowly progressive cases, diagnosis may be impeded by equivocal imaging results and mistaken for evolving upper motor neuron disease. As early imaging studies are lacking, we aimed to provide a detailed description of imaging and neurophysiology findings in a patient with aSCH, focusing on the early symptomatic stages.Case presentationWe here present the case of a 51-year old male patient with an episode of pain in the right trunk and a normal spinal MRI. After a symptom-free interval of 8 years, spasticity and paresis evolved in the right leg. There was subtle ventral displacement and posterior indentation of the thoracic spinal cord on MRI which, in retrospect, was missed as an early sign of aSCH. After another 3 years, symptoms spread to the left leg and a sensory deficit of the trunk became evident. Follow-up MRI now clearly showed an aSCH. Neurosurgical intervention consisted of remobilization of the herniated spinal cord and patch closure of the dura defect. Over the following years, motor and sensory symptoms partially improved.ConclusionsThe history of this patient with aSCH illustrates the importance of careful longitudinal clinical follow-up with repeated imaging studies in progressive upper motor neuron syndromes. Specific attention should be paid to a history of truncal pain and to MRI findings of a ventrally displaced spinal cord. Neurosurgical intervention may halt the progression of herniation.

Herniation despite Decompressive Hemicraniectomy in Large Hemispherical Ischemic Strokes

Despite decompressive hemicraniectomy (DHC), progressive herniation resulting in death has been reported following middle cerebral artery (MCA) strokes. We aimed to determine the surgical parameters measured on brain computed tomography (CT) scan that are associated with progressive herniation despite DHC in large MCA strokes. Retrospective chart review of medical records of patients with malignant hemispheric infarction who underwent DHC for cerebral edema was performed. Infarct volume was calculated on CT scans obtained within 24 hours of ictus. Radiological parameters of craniectomy bone flap size, brain volume protruding out of the skull, adequate centering of the craniectomy over the stroke bed, and the infarct volume outside the craniectomy bed (volume not centered [VNC]) were measured on the postoperative brain CT. Of 41 patients who underwent DHC, 7 had progressive herniation leading to death. Radiographic parameters significantly associated with progressive herniation included insufficient centering of craniectomy bed on the stroke bed (P = .03), VNC (P = .011), additional anterior cerebral artery infarction (P = .047), and smaller craniectomy length (P = .05). Multivariate logistic regression analysis for progressive herniation using craniectomy length and VNC as independent variables demonstrated that a higher VNC was significantly associated with progressive herniation despite surgery (P = .029). In large MCA strokes, identification of large infarct volume outside the craniectomy bed was associated with progressive herniation despite surgery. These results will need to be verified in larger prospective studies.

Laser treatment for stress urinary incontinence

Stress urinary incontinence (SUI) is defined as involuntary leakage of urine with increased intra-abdominal pressure. SUI is due to the progressive herniation of bladder, bladder neck and urethra from the anterior vaginal wall defect. Main defect in the anterior vagina is due to deficient collagen content of the endopelvic fascia.

Abstract WP339: Herniation Despite Decompressive Hemicraniectomy in Large Hemispherical Ischemic Stroke Patients

Background: Despite timely decompressive hemicraniectomy (DHC), clinical failure or progressive herniation requiring a second decompression procedure and mortality has been reported in acute middle cerebral artery (MCA) strokes. Hypothesis: Our objective was to determine the stroke and surgical parameters measured on head CT scan that are associated with progressive herniation despite DHC in patients with large hemispheric MCA strokes. Methods: Retrospective chart review of all medical records and imaging features of patients with malignant hemispheric infarction who underwent DHC for cerebral edema from July 2010 to June 2015, was performed. Patients who died from postoperative hemorrhagic complications were excluded. Infarct volume was calculated using ABC/2 method on CT scans within 48 hours of symptom onset (Kostov et al, 2012, World Neurosurg). Radiologic parameters of the craniectomy bone flap (length, width, area) and brain volume protruding out of the skull (height and volume) were measured (Chung et al, 2011, Neurologist). Images were reviewed by a board certified neuroradiologist to determine whether the craniectomy bed was sufficiently centered on the stroke bed (Zweckberger et al, 2014, Cerebrovasc Dis) and the brain volume not included in the craniectomy bed. Groups were compared using Fisher exact test for categorical variables and T-test or Mann-Whitney U test for continuous variables, as appropriate. Results: Out of 41 patients who underwent DHC for cerebral edema (mean age 53.1 ±12, 48.7% females, 36.5% African Americans) 7 had progressive herniation leading to mortality. Radiographic parameters that were significantly different between both groups were presence of malignant edema (p=0.047), insufficient centering of the craniectomy bed on the stroke bed (p=0.03), large infarct volume not centered on the craniectomy bed (p=0.011), presence of anterior cerebral artery infarction (p=0.047), and smaller craniectomy length (p=0.05). There was a trend in protruding brain volume (p=0.056). Conclusion: Besides the craniectomy length, sufficient centering of the craniectomy over the stroke bed may be required to prevent progressive herniation.

Para-oesophageal and parahiatal hernias in an Asian acute care tertiary hospital: an underappreciated surgical condition.

The prevalence of hiatal hernias and para-oesophageal hernias (PEHs) is lower in Asian populations than in Western populations. Progressive herniation can result in giant PEHs, which are associated with significant morbidity. This article presents the experience of an Asian acute care tertiary hospital in the management of giant PEH and parahiatal hernia. Surgical records dated between January 2003 and January 2013 from the Department of Surgery, Changi General Hospital, Singapore, were retrospectively reviewed. Ten patients underwent surgical repair for giant PEH or parahiatal hernia during the study period. Open surgery was performed for four patients with giant PEH who presented emergently, while elective laparoscopic repair was performed for six patients with either giant PEH or parahiatal hernia (which were preoperatively diagnosed as PEH). Anterior 180° partial fundoplication was performed in eight patients, and mesh reinforcement was used in six patients. The electively repaired patients had minimal or no symptoms during presentation. Gastric volvulus was observed in five patients. There were no cases of mortality. The median follow-up duration was 16.3 months. There were no cases of mesh erosion, complaints of dysphagia or recurrence of PEH in all patients. Giant PEH and parahiatal hernia are underdiagnosed in Asia. Most patients with giant PEH or parahiatal hernia are asymptomatic; they often present emergently or are incidentally diagnosed. Although surgical outcomes are favourable even with a delayed diagnosis, there should be greater emphasis on early diagnosis and elective repair of these hernias.

Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections: A Prospective, Double-Blind, Randomized Controlled Study

ObjectiveTo determine whether single injections of autologous platelet-rich plasma (PRP) into symptomatic degenerative intervertebral disks will improve participant-reported pain and function. DesignProspective, double-blind, randomized controlled study. SettingOutpatient physiatric spine practice. ParticipantsAdults with chronic (≥6 months), moderate-to-severe lumbar diskogenic pain that was unresponsive to conservative treatment. MethodsParticipants were randomized to receive intradiskal PRP or contrast agent after provocative diskography. Data on pain, physical function, and participant satisfaction were collected at 1 week, 4 weeks, 8 weeks, 6 months, and 1 year. Participants in the control group who did not improve at 8 weeks were offered the option to receive PRP and subsequently followed. Main Outcome MeasuresFunctional Rating Index (FRI), Numeric Rating Scale (NRS) for pain, the pain and physical function domains of the 36-item Short Form Health Survey, and the modified North American Spine Society (NASS) Outcome Questionnaire were used. ResultsForty-seven participants (29 in the treatment group, 18 in the control group) were analyzed by an independent observer with a 92% follow-up rate. Over 8 weeks of follow-up, there were statistically significant improvements in participants who received intradiskal PRP with regards to pain (NRS Best Pain) (P = .02), function (FRI) (P = .03), and patient satisfaction (NASS Outcome Questionnaire) (P = .01) compared with controls. No adverse events of disk space infection, neurologic injury, or progressive herniation were reported following the injection of PRP. ConclusionParticipants who received intradiskal PRP showed significant improvements in FRI, NRS Best Pain, and NASS patient satisfaction scores over 8 weeks compared with controls. Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up. Although these results are promising, further studies are needed to define the subset of participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP injectate.

Early Metabolic/Cellular-Level Resuscitation Following Terminal Brain Stem Herniation

Patients with terminal brain stem herniation experience global physiological consequences and represent a challenging population in critical care practice as a result of multiple factors. The first factor is severe depression of consciousness, with resulting compromise in airway stability and lung ventilation. Second, with increasing severity of brain trauma, progressive brain edema, mass effect, herniation syndromes, and subsequent distortion/displacement of the brain stem follow. Third, with progression of intracranial pathophysiology to terminal brain stem herniation, multisystem consequences occur, including dysfunction of the hypothalamic-pituitary axis, depletion of stress hormones, and decreased thyroid hormone bioavailability as well as biphasic cardiovascular state. Cardiovascular dysfunction in phase 1 is a hyperdynamic and hypertensive state characterized by elevated systemic vascular resistance and cardiac contractility. Cardiovascular dysfunction in phase 2 is a hypotensive state characterized by decreased systemic vascular resistance and tissue perfusion. Rapid changes along the continuum of hyperperfusion versus hypoperfusion increase risk of end-organ damage, specifically pulmonary dysfunction from hemodynamic stress and high-flow states as well as ischemic changes consequent to low-flow states. A pronounced inflammatory state occurs, affecting pulmonary function and gas exchange and contributing to hemodynamic instability as a result of additional vasodilatation. Coagulopathy also occurs as a result of consumption of clotting factors as well as dilution of clotting factors and platelets consequent to aggressive crystalloid administration. Each consequence of terminal brain stem injury complicates clinical management within this patient demographic. In general, these multisystem consequences are managed with mechanism-based interventions within the context of caring for the donor’s organs (liver, kidneys, heart, etc.) after death by neurological criteria. These processes begin far earlier in the continuum of injury, at the moment of terminal brain stem herniation. As such, aggressive, mechanism-based care, including hormonal replacement therapy, becomes clinically appropriate before formal brain death declaration to support cardiopulmonary stability following terminal brain stem herniation.

Management of Delayed Presentation of a Right‐Side Traumatic Diaphragmatic Rupture

Right-side diaphragmatic rupture is an unusual condition after blunt trauma. The diagnosis may be missed during the early period of trauma and may lead to progressive herniation of intraabdominal contents into the thorax. In this study, we aimed to evaluate the diagnosis and treatment options for the late diagnosis of cases of right-side traumatic diaphragmatic rupture. We evaluated the patients with diaphragmatic hernia who were admitted to the hospital during an 8-year period. Only patients with a right-side diaphragmatic hernia and a history of high-energy trauma were included in the study. Patients with left-side diaphragmatic hernia or those who were subjected to emergency operation due to diaphragmatic rupture were excluded from the study. Patient characteristics, clinical presentations, diagnostic tools, and treatment options were evaluated. Eight patients (five men, three women) were enrolled in the study. The most common trauma type was a traffic accident, and the average interval between the trauma and diagnosis was 10 years. Thoracoabdominal computed tomography had high sensitivity and specificity for visualizing the diaphragmatic hernia. No predisposing factor was found to add laparotomy to thoracotomy. There was no postoperative mortality, and no late complications were observed at the assessments during the 45-month follow-up. Clinical presentation of late diagnosed diaphragmatic hernia, which is encountered only rarely on the right side, requires diagnostic and therapeutic approaches different from those associated with acute diaphragmatic rupture. It should not be forgotten during the differential diagnosis in patients with a history of trauma.

Diagnosis of a Craniopharyngioma After Acute Brainstem Herniation in an Emergency Department

A 9-year-old previously healthy girl presented with 3 weeks of intermittent emesis and headache to a community emergency department, where she had rapid decompensation due to increased intracranial pressure. Head computed tomography revealed a calcified suprasellar mass consistent with a craniopharyngioma. Despite medical and surgical intervention, the patient had progression of herniation with global cerebral infarction, and care was withdrawn. Although craniopharyngiomas are typically thought to be benign, slow-growing intracranial tumors, this case emphasizes the need for an expeditious diagnostic evaluation when symptoms that may be referable to intracranial hypertension are evident. Craniopharyngiomas and emergency management of intracranial hypertension are reviewed.

Intracranial hemorrhage after high-dose methylprednisolone in a child with acute immune thrombocytopenic purpura

Dear Editor, Severe hemorrhage in children with immune thrombocytopenic purpura (ITP) is rare and occurs in 3% of patients [1]. Intracranial hemorrhage (ICH), the most feared bleeding complication, has an estimated incidence of 0.1–0.5% [1–3]. Mortality rate of ICH is high and varies from 24–57% [2–4]. We report a patient with acute ITP who developed fatal ICH shortly after starting high-dose methylprednisolone. A 5-year-old girl with an unremarkable medical and family history presented to her pediatrician with acute onset of bruising and petechiae. Physical examination revealed no other abnormalities. Blood pressure was 112/60 mmHg. Laboratory studies showed an isolated trombocytopenia of 1 × 109/L (Table 1). She was diagnosed with acute ITP and managed conservatively. Four days after presentation, she developed large ecchymoses and epistaxis causing anemia. Intravenous immunoglobulins (IVIg; 0.8 g/kg once) and packed red cells were administered (Fig. 1). Platelet count remained low (1 × 109/L) and mucosal bleeding continued. The girl was referred to our department for further management. We saw a pale, tachycardic girl with multiple ecchymoses and active mucosal bleeding from nose and mouth. Hemoglobin was 7.4 g/dL and platelet count 2 × 109/L. After a second gift of IVIg, prednisone 2 mg/kg/day, an erythrocyte transfusion and a large dose of platelets (ten donor units), platelet count rose to 21 × 109/L, hemoglobin stabilized and the clinical condition of our patient improved dramatically. However, 36 h later, profuse mucosal bleeding from nose and mouth recurred at a platelet count of 1 × 109/L. We started high-dose methylprednisolone (15 mg/kg) together with another platelet transfusion. Shortly after starting the methylprednisolone infusion, she complained of severe headache and instantly developed generalized seizures. Blood pressure at that moment was elevated: 170/90 mmHg. Computed tomography (CT) showed extensive bifrontal ICH. Unfortunately, our patient died of progressive herniation caused by massive cerebral edema, despite continuous platelet transfusions and intensive care management. Autopsy was not performed. Table 1 Results of laboratory studies in our patient Fig. 1 Overview of platelet counts and interventions in our patient. i = IVIg; white bar = prednisone 2 mg/kg/day; white arrow = high-dose methylprednisolone infusion; black circle = platelet transfusion; black diamond = erythrocyte transfusion. ... The main reason for clinicians to treat children with acute ITP and minor bleeding symptoms is to raise platelet counts in order to prevent severe bleeding complications and in particular ICH. The question is whether treatment really prevents these bleeding complications. The majority of children with severe bleeding or ICH described in literature developed these complications despite prior therapy [1–5]. Why do some patients develop ICH despite therapy? Apart from known risk factors like head trauma, use of non-steroidal anti-inflammatory drugs, intracranial arteriovenous malformation, and bleeding beyond petechiae and ecchymoses [2, 3], there are some other possible explanations. Patients may suffer from refractory ITP and remain severely thrombocytopenic despite therapy, leaving them at risk for bleeding complications [6]. However, there is also a possibility of either causing or worsening ICH due to adverse effects of drug therapy. In our patient, the temporal relationship between starting methylprednisolone and development of headache and ICH remains remarkable. A sudden rise in blood pressure, a known adverse effect of high-dose methylprednisolone, could have initiated or worsened ICH. In conclusion, this report shows that treatment of ITP cannot always prevent ICH and may even be involved in initiating or worsening ICH.

Traumatic Diaphragmatic Hernia: An Unusual Complication of Colonoscopy

Purpose: We report a case of diaphragmatic herniation during a colonoscopy, via an occult diaphragmatic weakness from the patient's prior trauma. A 68 y/o male underwent screening colonoscopy with sigmoid polypectomy. The procedure was unremarkable and well tolerated. Five days later, he presented to the hospital with left upper and bilateral lower abdominal crampy pain, associated with nausea, vomiting, loss of appetite, and abdominal distension with no BM for last 5 days. One year prior, he had been involved in a fall, with blunt trauma to his left lateral thorax resulting in multiple rib fractures with flail segment and hemothorax, which was treated with closed thoracostomy drainage. Chest X-ray showed focal elevation of the left diaphragm after treatment for hemothorax. However, the diaphragm appeared intact on CT. Review of systems was remarkable for mild intermittent left upper abdominal pain with early satiety and nausea for several months with worsening of his symptoms for last 5 days since colonoscopy. Physical examination revealed: mild abdominal distension with tympany, tenderness in left upper quadrant and hypoactive bowel sounds. Abdominal-X-ray showed protrusion of the large bowel into the left thoracic cavity along with elevation of the left diaphragm. There was no free air in the peritoneal cavity. Abdominal CT confirmed the herniation of the splenic flexure through a defect in the midportion of the left hemidiaphragm. The proximal colon and terminal ileum were dilated with air-fluid levels consistent with bowel obstruction. Subsequently, the patient underwent exploratory laparotomy which showed left diaphragmatic hernia and incarcerated colon and omentum with colonic obstruction. A reduction repair of the hernia was performed and patient was discharged with an uncomplicated post-op course. Diaphragmatic rupture develops in about 5% of cases of blunt abdominal trauma, and is more frequent on the left side. It may be asymptomatic and diagnosis may be delayed for many years. Because the intraabdominal pressure is higher than intrathoracic pressure, progressive herniation of abdominal contents may occur through the defect. Undiagnosed traumatic diaphragmatic hernia encountered during colonoscopy has been rarely reported. Colon perforation leading to tension pneumothorax has also been described. However, in our case, the patient had no evidence of a diaphragmatic defect after trauma or treatment for left hemothorax. Continuous insufflation of air during the colonoscopy seems to have induced an increase in intra-abdominal pressure, which resulted in conversion of an occult focal diaphragmatic weakness into a true defect leading to sudden herniation of the colon into the thoracic cavity.

Diagnosis and management of fetal intrapericardial Morgagni diaphragmatic hernia with massive pericardial effussion

Herniation of the liver into the fluid-filled pericardial sac resulting in a thoracic mass is a particularly rare form of Morgagni hernia (congenital diaphragmatic hernia of Morgagni). We report an early antenatal diagnosis of congenital diaphragmatic hernia of Morgagni with pericardium effussion at 21 weeks' gestation. Two pericardiocentesis were performed at 21 and 22 4/7 weeks' gestation because of recurrence of pericardial effussion. Regular ultrasound assessments showed progressive herniation of the liver to practically fill the right hemithorax. An ex utero intrapartum treatment procedure was performed at 37 weeks' gestation to rescue maximum intrathoracic space for ventilation of the remaining functional lung tissue and to establish an airway for postnatal support. After birth, the patient successfully underwent early correction of the hernia. Postoperative course was uneventful, and the newborn girl was discharged 18 days later without complications and is currently doing well.

Intervertebral Disc Segmentation and Volumetric Reconstruction From Peripheral Quantitative Computed Tomography Imaging

An automatic system for segmenting and constructing volumetric representations of excised intervertebral discs from peripheral quantitative computed tomography (PQCT) imagery is presented. The system is designed to allow for automatic quantitative analysis of progressive herniation damage to the intervertebral discs under flexion/extension motions combined with a compressive load. Automatic segmentation and volumetric reconstruction of intervertebral disc from PQCT imagery is a very challenging problem due to factors such as streak artifacts and unclear material density separation between contrasted intervertebral disc and surrounding bone in the PQCT imagery, as well as the formation of multiple contrasted regions under axial scans. To address these factors, a novel multiscale level set approach based on the Mumford-Shah energy functional in iterative bilateral scale space is employed to segment the intervertebral disc regions from the PQCT imagery. A Delaunay triangulation is then performed based on the set of points associated with the intervertebral disc regions to construct the volumetric representation of the intervertebral disc. Experimental results show that the proposed system achieves segmentation and volumetric reconstructions of intervertebral discs with mean absolute distance error below 0.8 mm when compared to ground truth measurements. The proposed system is currently in operational use as a visualization tool for studying progressive intervertebral disc damage.

Evaluation of Age-Related Intraorbital Fat Herniation through Computed Tomography

Progressive herniation of lower eyelid fat has generally been accepted as a part of the aging process in the lower eyelid. Numerous theories have been proposed for the mechanism of periorbital aging, but to the best of the authors' knowledge, the actual occurrence of lower eyelid fat herniation has not been documented. Using data of orbital and facial computed tomography from 167 patients, the authors evaluated curvature and protrusion of lower eyelid fat and its changes in different age groups. The relation of its occurrence to the position of the ocular globe was also evaluated. A statistically significant effect of age groups was detected for curvature (percent) of lower eye lid fat. Specifically, when compared with the reference group (younger than 30 years), each increase of 1 year shows a curvature increase of 0.48 percent for the group that was 30 to 69 years old (95 percent confidence interval, 0.27 to 0.69; p < 0.01). For the age group of 70 years or older, each increase of 1 year could predict a 1.22 percent increase of curvature (95 percent confidence interval, 0.81 to 1.63; p < 0.01). The authors found that although the amount of lower eyelid fat varies greatly between individuals, the process of lower eyelid fat herniation does occur. It retains a steady incline after the third decade of life and slows at approximately age 70. In the authors' study, ocular globe position appears unrelated to this process of herniation.

Surgical management of cerebellar tonsillar herniation in three patients with macrocephaly–cutis marmorata telangiectatica congenita

The authors report on three patients with a congenital brain overgrowth syndrome, macrocephaly-cutis marmorata telangiectatica congenita (M-CMTC), who experienced neurological sequelae associated with herniation of the cerebellar tonsils through the foramen magnum. In two of these patients, the authors document postnatal brain overgrowth that contributed to recurrent descent of the cerebellar tonsils and complicated the surgical treatment in one of the patients. The authors address the neurosurgical concerns related to this syndrome with special attention to acquired tonsillar ectopia and postulate that some patients may be at risk for progressive tonsillar herniation and consequent neurological symptoms due to cerebellar overgrowth. Ectopic cerebellar tonsils have been reported previously in cases of M-CMTC, and this phenomenon may be a secondary event associated with brain overgrowth rather than due to a congenitally small posterior fossa.

The direction of progressive herniation in porcine spine motion segments is influenced by the orientation of the bending axis

Background. It has been shown that disc herniations are a cumulative injury created by repetitive flexion motion while under modest compressive loads. There is a lack of data linking the direction of nucleus tracking to the orientation of the bending motion axis. Our purpose was to determine if the direction that the nucleus tracks through the annulus during progressive herniation is predictable from the direction of bending motion (i.e. a specific side with posterio-lateral herniation). Methods. Matched cohorts (nu = 16) of porcine cervical spine (C3/4 and C5/6) motion segments were potted in aluminum cups and bent at an angle of 30° to the sagittal plane flexion axis while under a sustained compressive load of 1472 N. Findings. The direction of bending motion affected the tracking pattern of the nucleus through the annular fibres in a predictable pattern. Specifically, bending the motion segments at an angle of 30° to the left of the sagittal plane flexion axis biased the movement of the nucleus toward the posterior right side of the disc in 15 of the 16 specimens. Interpretation. Based on this animal model, shown to have similar biomechanical behaviour to humans, the direction that the nucleus tracks through the annular fibres appears to be dependent upon the direction of bending motion. This may have implications on both herniation prevention and rehabilitation of posterio-lateral bulges and herniations.

Hydrocephalus Requiring Urgent External Ventricular Drainage in a Patient with Diabetic Ketoacidosis and Cerebral Edema: Case Report

Neurological deterioration, typically attributed to cerebral edema, is a rare but life-threatening complication in the treatment of diabetic ketoacidosis (DKA). We report the case of a child with DKA who became comatose but demonstrated acute obstructive hydrocephalus, instead of cerebral edema. An 11-year-old male patient presented with new-onset insulin-dependent diabetes mellitus and DKA. He was initially responsive but, after several hours of treatment, became unresponsive, with dilated pupils and decerebrate posturing. Cranial computed tomographic scanning demonstrated obstructive hydrocephalus resulting from focal cerebellar and brain stem edema. The patient was initially managed with medical treatment but ultimately required urgent ventricular drainage to arrest a progressive herniation syndrome. To our knowledge, this report describes only the second such case reported and the first requiring urgent ventriculostomy. These observations emphasize the importance of recognizing hydrocephalus as a potentially reversible cause of coma in DKA and of initiating prompt neurosurgical intervention, if warranted.