J Neurosurg

Surgical treatment of spontaneous spinal cerebrospinal fluid leaks.

Schievink WI. Morreale VM. Atkinson JL. Meyer FB. Piepgras DG. Ebersold MJ.
Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
OBJECT: Spontaneous spinal cerebrospinal fluid (CSF) leaks are an increasingly recognized cause of intracranial hypotension and may require neurosurgical intervention. In the present report the authors review their experience with the surgical management of spontaneous spinal CSF leaks. METHODS: Between 1992 and 1997, 10 patients with spontaneous spinal CSF leaks and intracranial hypotension were treated surgically. The mean age of the seven women and three men was 42.3 years (range 22-61 years). Preoperative imaging showed a single meningeal diverticulum in two patients, a complex of diverticula in one patient, and a focal CSF leak alone in seven patients. Surgical exploration in these seven patients demonstrated meningeal diverticula in one patient; no clear source of CSF leakage could be identified in the remaining six patients. Treatment consisted of ligation of the diverticula or packing of the epidural space with muscle or Gelfoam. Multiple simultaneous spinal CSF leaks were identified in three patients. CONCLUSIONS: All patients experienced complete relief of their headaches postoperatively. There has been no recurrence of symptoms in any of the patients during a mean follow-up period of 19 months (range 3-58 months; 16 person-years of cumulative follow up). Complications consisted of transient intracranial hypertension in one patient and leg numbness in another patient. Although the disease is often self-limiting, surgical treatment has an important role in the management of spontaneous spinal CSF leaks. Surgery is effective in eliminating the headaches and the morbidity is generally low. Surgical exploration for a focal CSF leak, as demonstrated on radiographic studies, usually does not reveal a clear source of the leak. Some patients may have multiple simultaneous CSF leaks.

Idiopathic spinal cord herniation. Report of two cases and review of the literature.

Miyake S. Tamaki N. Nagashima T. Kurata H. Eguchi T. Kimura H.
Department of Neurosurgery, Kobe University School of Medicine, Hyogo, Japan.
The authors describe two occurrences of idiopathic spinal cord herniation, an entity that has been reported previously in only 11 cases. The patients described in this report presented in midlife with Brown-Sequard syndrome. Computerized tomography myelography and magnetic resonance (MR) imaging showed ventral displacement of the spinal cord with no apparent dorsal mass. Intraspinal cerebrospinal fluid (CSF) flow studies in which phase-contrast pulse sequence cine MR imaging was used displayed a normal pattern dorsal to the spinal cord. Percutaneous intrathecal endoscopic observation did not disclose dorsal intradural cysts, but ventral adhesions were seen between the spinal cord and the dura. Microsurgical intradural exploration revealed ventrolateral herniation of the cord and a ventral root through a dural defect into an epidural arachnoid cyst. The adhesions were released, the cord was repositioned intradurally, and the dural defect was patched. The patients showed gradual improvement postsurgery, as did most of the patients in the previously reported cases. The CSF flow and endoscopic studies were found to be particularly informative, and dural patching with surgical membrane is recommended.

Hydrothorax after ventriculoperitoneal shunt placement in a premature infant: an iatrogenic postoperative complication. Case report.

Faillace WJ. Garrison RD.
Department of Neurosurgery, University of Florida, Jacksonville 32209, USA.
The authors describe the case of a prematurely born infant who developed hydrothorax after ventriculoperitoneal (VP) shunt placement for treatment of posthemorrhagic communicating hydrocephalus. Prior to shunt placement a bout of necrotizing enterocolitis created intense abdominal and peritoneal scarring. The authors postulate that the scarring created poor peritoneal absorption capacity of cerebrospinal fluid (CSF), with preferential flow of CSF from the peritoneal to the pleural cavity. A (99m)Tc-diethylenetriamine pentaacetic acid radionucleotide study enabled the authors to rule out shunt malfunction, and preferential transdiaphragmatic flow of CSF from the abdomen to the thoracic cavity was demonstrated. The hydrothorax resolved after conversion of the VP shunt to a ventriculoatrial shunt. Respiratory distress after VP shunt placement should be considered an unusual but important sentinel symptom in the differential diagnosis of postoperative shunt complications.

Congenital tethered spinal cord syndrome in adults.

Year 1998
Iskandar BJ. Fulmer BB. Hadley MN. Oakes WJ.
Division of Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama 35233, USA.
OBJECT: The management of tethered spinal cord syndrome with onset of symptomatology occurring in adulthood remains controversial, although the necessity of early surgery in the pediatric tethered cord syndrome population is well established. To ascertain the results of surgery in adult patients with this anomaly, the authors undertook a retrospective review of 34 cases. METHODS: The authors studied the hospital records of 34 consecutive patients who presented in adulthood with tethered cord syndrome and conducted follow-up phone interviews with 28 of them. The population consisted of 12 men and 22 women, ranging in age from 18 to 70 years (mean 34 years). The most common presenting feature was pain, followed by weakness and incontinence. All patients underwent surgery. The most common operative findings were tight filum terminale, split cord malformation, and lipomyelomeningocele, paralleling those observed in pediatric studies. Long-term surgical results and patient outcome ratings were encouraging. After a mean clinical follow-up period of 4 years, significant improvement occurred in 22 of 27 patients presenting with pain, 13 of 27 patients with motor or sensory dysfunction, and 11 of 18 patients with bowel and bladder disturbance. In addition, telephone interviews were obtained after a period of 8.6 years. Twenty-two (79%) of 28 patients called the operation a long-term success; 21 (75%) of 28 patients believed that they had significant postoperative improvement (and not just stabilization) in pain and/or neurological function. Surgical complications were generally minor. Nineteen (86%) of 22 employed patients returned to work after surgery. Two (33%) of six patients who were not employed before surgery worked full time postoperatively. Only two of the 28 patients interviewed had received Workers' Compensation benefits; both of these had good outcomes and returned to work. CONCLUSIONS: Tethered spinal cord syndrome in adults is an uncommon entity that can become symptomatic. Although surgery in adults involves greater risk of neurological injury than in children, it is a low-risk procedure with encouraging results. Because neurological deficits are generally irreversible, early surgery is recommended.