Cerebrospinal fluid leakage: agarose gel electrophoresis detection of beta(2)-transferrin and nephelometric quantification of beta-trace protein.
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Electrophoresis, Agar Gel↗
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Results for “Subdural Effusion”
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Ossification of the posterior longitudinal ligament. Results of anterior cervical decompression and arthrodesis in sixty-one North American patients.
BACKGROUND: Ossification of the posterior longitudinal ligament is commonly associated with cervical myelopathy. Surgical treatment is a matter of controversy. We report on a series of patients who were managed with anterior cervical decompression and arthrodesis for the treatment of cervical myelopathy associated with ossification of the posterior longitudinal ligament. METHODS: We retrospectively reviewed the records for all sixty-five patients who had been managed with anterior decompression and arthrodesis for the treatment of cervical ossification of the posterior longitudinal ligament and associated neurologic compression from 1982 to 2001. Sixty-one patients (thirty-nine men and twenty-two women) were followed for at least two years (or until the time of death). The average number of vertebrae resected was 2.2. The average duration of follow-up for the sixty surviving patients was four years (range, two years to fifteen years and four months). The preoperative, six-week postoperative, and final follow-up clinical status (including neurological function as assessed with the Nurick grading system) was recorded for each patient. RESULTS: Fifty-six of the sixty-one patients had neurological improvement, with an average improvement of 1.5 Nurick grades at the time of the final follow-up. Eight patients had absent dura at the time of surgery and, of these, five had development of a cerebrospinal fluid fistula. Eight patients had development of new neurological signs and/or symptoms in the upper extremity postoperatively. Eight patients required reoperation because of a painful pseudarthrosis (one patient), strut-graft dislodgment (three), cerebrospinal fluid leakage (three), or compression of a nerve root caudad to the area of the original procedure (one). One patient died as the result of cardiac arrest on the third postoperative day. Fifty-eight patients had an osseous fusion, one had an asymptomatic nonunion, and one had a symptomatic pseudarthrosis that was treated with revision surgery. CONCLUSIONS: Anterior decompression and arthrodesis is an effective way to achieve pain relief and neurological improvement in North American patients of non-Asian descent who have cervical myelopathy associated with ossification of the posterior longitudinal ligament. The risk of durocutaneous fistula, graft dislodgment, and postoperative neurological symptoms appears to be high in patients with cervical myelopathy associated with this condition.
Arthrodesis↗
Intracranial hypotension due to cerebrospinal fluid leakage detected by radioisotope cisternography.
Seven patients, six females and one male aged 26 to 39 years old, presented with headache in the upright posture, which was completely relieved in the recumbent posture. Radioisotope cisternography with technetium-99m-human serum albumin detected cerebrospinal fluid (CSF) leakage at the cervicothoracic level in six patients, and at the high cervical level in one patient. The diagnosis was intracranial hypotension due to spontaneous CSF leakage. Complete bed rest for more than 2 weeks resulted in complete resolution of the headache in all patients, and follow-up cisternography showed no leakage. Radioisotope cisternography is useful for the diagnosis of spontaneous CSF leakage, and complete bed rest for more than 2 weeks may be the best method of treatment.
Adult↗
Multi-level disruption of the spinal nerve root sleeves in spontaneous spinal cerebrospinal fluid leakage--two case reports.
A 37-year-old male and an 18-year-old male presented with spontaneous spinal cerebrospinal fluid (CSF) leakage from multiple nerve root sleeves. Both patients suffered abrupt onset of intense headache followed by nausea, dizziness, and one patient with and one without positional headache. Radioisotope spinal cisternography of both patients revealed that the CSF leaks were not localized in a special zone but distributed to multiple spinal nerve root sleeves. Magnetic resonance (MR) myelography suggested that the spinal CSF column was fully expanded to the root sleeves. The extraspinal nerve bundles demonstrated numerous high intensity spots. Both patients were treated conservatively, and their symptoms resolved within one month. Repeat radioisotope cisternography and MR myelography confirmed the spine was normal after recovery. We suggest that spreading disruption of the arachnoid membrane occurs at the nerve root sleeves due to CSF overflow into the spinal canal.
Adolescent↗
Transoral transclival approach for intradural lesions using a protective bone baffle to block cerebrospinal fluid pulse energy--two case reports.
The transoral transclival approach for the treatment of intradural lesions of the clivus is often associated with serious complications such as cerebrospinal fluid (CSF) leakage and meningitis. CSF pulse energy may be the most significant factor in CSF leakage and meningitis, but a bone baffle can block such CSF pulse energy. A 64-year-old female presented with sudden onset of severe headache. She had subarachnoidal hemorrhage due to a rupture of the vertebral-posterior inferior cerebellar artery aneurysm. A 66-year-old female complaining of occipitalgia and numbness of the extremities had a foramen magnum meningioma. Both patients were treated via the transoral transclival route with a protective bone baffle, obtained from the iliac bone, securely fixed in the bone window to protect the repaired dura from injury by CSF pulse energy. Neither patient showed CSF leakage or meningitis, and the period of continuous lumbar CSF drainage was only 7 days. The transoral transclival approach with a bone baffle is still very effective in selected cases.
Aged↗
Subdural hygroma as a complication of endoscopic neurosurgery--two case reports.
Two cases of subdural hygroma occurred in a series of 77 neuroendoscopic procedures. An 8-year-old boy underwent neuroendoscopic cysto-cisternostomy of a left temporal arachnoid cyst. Routine postoperative magnetic resonance imaging 7 days later showed a large left-sided subdural hygroma without clinical symptoms. During the following 3 months, the subdural hygroma did not resolve spontaneously, so it was drained through a burr hole. A 3-month-old boy with aqueductal stenosis developed bilateral subdural hygromas after third ventriculostomy. Several punctures through the open anterior fontanelle relieved the hygromas but increasing head circumference required ventriculoperitoneal shunting 12 months later. Complications of neuroendoscopic procedures are increasingly reported, including various kinds of bleeding, infections, or damage of neuronal tissue. Only three previous cases of subdural hygroma or hematoma after neuroendoscopic interventions have been reported. The possible etiologies and clinical consequences of this rare complication have to be considered before selecting neuroendoscopy treatment.
Child↗
Ascending meningitis secondary to traumatic cerebrospinal fluid leaks.
Cerebrospinal fluid (CSF) leakage may cause immediate or delayed complications, such as ascending meningitis and brain abscess, potentially lethal complications that may appear years or decades after the trauma. Thus, the initial treatment of a CSF fistula may decisively influence long-term outcome. In a retrospective study including 1036 consecutive patients presenting with severe cranial trauma from May 1990 to March 1996, we identified 27 patients (2.6%) with CSF fistulas. Patients with a post-traumatic CSF leak were most commonly males between 15 and 40 years involved in a motor vehicle accident. The most common sites of injury were the frontal area and anterior skull base for those patients with rhinorrhea and the temporal bone for those patients with otorrhea. A transcranial repair was used for large cranial base defects (n = 10), while conservative treatment, comprised of bedrest, lumbar drainage, and medications, was used for smaller fistulas (n = 17). Four patients (40%) initially treated with a transcranial repair, and five patients (29%) initially treated conservatively, developed a meningitis. Therefore, neither the conservative approach nor the transcranial repair was able to prevent this considerable incidence of ascending meningitis. We believe that the high incidence of meningitis is not acceptable; thus, we are now evaluating early intervention using endoscopic techniques for the identification and/or repair of post-traumatic fistulas.
Adolescent↗
A case of holoprosencephaly with atypical CT findings and no facial anomaly.
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Brain↗
Persistent posttraumatic cerebrospinal fluid leakage.
OBJECT: Persistent posttraumatic cerebrospinal fluid (CSF) leakage frequently complicates skull base fractures. Although many CSF leaks will cease without treatment, patients with CSF leaks that persist greater than 24 hours may be at increased risk for meningitis, and many will require surgical intervention. The authors reviewed their 15-year experience with posttraumatic CSF leaks that persisted longer than 24 hours. METHODS: The authors reviewed the medical records of 51 patients treated between 1984 and 1998 with CSF leaks that persisted for 24 hours or longer after traumatic head injury. In 27 patients (55%) spontaneous resolution of CSF leakage occurred at an average of 5 days posttrauma. In 23 patients (45%) surgery was required to resolve the leakage. Eight patients (16%) with occult CSF leaks presented with recurrent meningitis at an average of 6.5 years posttrauma. Forty-three (84%) patients with CSF leaks sustained a skull fracture, most commonly involving the frontal sinus, whereas parenchymal brain injury or extraaxial hematoma was demonstrated in only 18 patients (35%). Delayed CSF leaks, with an average onset of 13 days posttrauma, were observed in eight patients (16%). Among patients with clinically evident CSF leakage, the frequency of meningitis was 10% with antibiotic prophylaxis, and 21% without antibiotic prophylaxis. Thus, prophylactic antibiotic administration halved the risk of meningitis. A variety of surgical approaches was used, and no significant neurological morbidity occurred. Three (13%) of 23 surgically treated patients required additional surgery to treat continued CSF leakage. CONCLUSIONS: A significant proportion of patients with CSF leaks that persist greater than 24 hours will require surgical intervention. Prophylactic antibiotic therapy may be effective in this group of patients. Patients with skull base or frontal sinus fractures should be followed to detect the occurrence of delayed leakage. Surgery-related outcome is excellent.
Adolescent↗
Diagnosis and management of posttraumatic oculorrhea.
Posttraumatic cranio-orbital cerebrospinal fluid (CSF) fistula is very rare. Diagnosis of these fistulas may be difficult, and it is possible that this complication of craniofacial injury is underdiagnosed. Early recognition and adequate treatment is of paramount importance to prevent hazardous complications. The authors report the case of a 20-year-old woman in whom a CSF leak developed through the medial canthus area of her eye after she sustained a mild sports-related injury. Clinical examination and chemical analysis of the fluid led to the correct diagnosis, and the leak was stopped with conservative treatment. It is proposed that a CSF leak through the eye be termed "oculorrhea" as compared with otorrhea and rhinorrhea. The mechanism of the fistula in this patient is discussed, as is the pertinent radiologically demonstrated anatomy and the mechanism of injury. Management and controversies are also discussed.
Adult↗
Cerebrospinal fluid leaks following spinal or posterior fossa surgery: use of fat grafts for prevention and repair.
Cerebrospinal fluid (CSF) leaks are relatively common following spinal or posterior fossa surgery. A midline dural tear in the spine is readily repaired by direct application of a suture. However, far-lateral or ventral dural tears are problematic. Fat is an ideal sealant because it is impermeable to water. In this paper the author reports his experience with using fat grafts for the prevention or repair of CSF leaks and proposes a technique in which a large sheet of fat, harvested from the patient's subcutaneous layer, is used to cover not only the dural tear(s) but all of the exposed dura and is tucked into the lateral recess. This procedure prevents CSF from seeping around the fat, which may be tacked to the dura with a few sutures. Fibrin glue is spread on the surface of the fat and is further covered with Surgicel or Gelfoam. For ventral dural tears (associated with procedures in which disc material is excised), fat is packed into the disc space to seal off the ventral dural leak. Leaks in the posterior fossa are managed similarly to those in the spine. Dural suture lines, following suboccipital or spinal intradural exploration, are prophylactically protected from CSF leakage in the same manner. With one exception, 27 dural tears noted during 1650 spinal procedures were successfully repaired using this technique. There was one case of postoperative CSF leakage in 150 cases in which intradural exploration for tumor or other lesions was undertaken. Both postoperative CSF leaks were controlled by applying additional skin sutures. The use of a fat graft is recommended as a rapid, effective means of prevention and repair of CSF leaks following posterior fossa and spinal surgery.
Adipose Tissue↗
Review of spinal pseudomeningoceles and cerebrospinal fluid fistulas.
Spinal pseudomeningoceles and cerebrospinal fluid (CSF) fistulas are uncommon extradural collections of CSF that may result from inadvertent tears in the dural-arachnoid layer, traumatic injury, or may be congenital in origin. Most pseudomeningoceles are iatrogenic and occur in the posterior lumbar region following surgery. The true incidence of iatrogenic pseudomeningoceles following laminectomy or discectomy is unknown; however, the authors of several published reports suggest that the incidence of lumbar pseudomeningoceles following laminectomy or discectomy is between 0.07% and 2%. Pseudomeningoceles are often asymptomatic, but patients may present with recurrence of low-back pain, radiculopathy, subcutaneous swelling, or with symptoms of intracranial hypotension. Very rarely, they present with delayed myelopathy. Although magnetic resonance imaging is the neurodiagnostic study of choice, computerized tomography myelography and radionuclide myelographic study may be helpful diagnostic tools in some cases. Analysis of suspect fluid for Beta2 transferrin may be a useful adjunctive study. Treatment options include close observation for spontaneous resolution, conservative measures such as bed rest and application of an epidural blood patch, lumbar subarachnoid drainage, and definitive surgical repair.
Diskectomy↗
Cerebrospinal fluid volume depletion and its emerging clinical/imaging syndromes.
Cerebrospinal fluid (CSF) volume depletion, due to CSF leakage or CSF shunt overdrainage, is typically indicated when patients present with orthostatic headaches, with or without several other symptoms: neck or interscapular pain, nausea, emesis, diplopia, changes in hearing, visual blurring, facial numbness or weakness, and radicular upper-limb symptoms. Cerebrospinal fluid pressures typically are quite low and head magnetic resonance images typically reveal diffuse pachymeningeal gadolinium enhancement, with or without evidence of sagging of the brain and less frequently with subdural fluid collections, enlarged cerebral venous sinuses or pituitary gland or decreased ventricular size. Magnetic resonance imaging has revolutionized detection of spontaneous CSF leaks, leading to identification of far more cases and recognition of several clinical/imaging forms of presentation of the disorder. These forms, which are different from the "typical" presentation, include a group with consistently normal CSF pressures (normal pressure), another group without abnormal meningeal enhancement (normal meninges), and a group without headache (acephalic). Each of these forms can be seen in a setting of documented and ongoing CSF volume depletion. Awareness of CSF volume depletion is increasing, and its clinical and imaging spectrum is broadening.
Arachnoid↗
Surgical treatment of spontaneous spinal cerebrospinal fluid leaks.
Spontaneous spinal cerebrospinal fluid (CSF) leaks are an increasingly recognized cause of intracranial hypotension. In this report the authors review the indications for surgery, surgical techniques, and surgery-related outcomes for these lesions. The major presenting symptoms include postural headaches, nausea, vomiting, and diplopia. Often, there is no history of traumatic injury. The most common cranial magnetic resonance (MR) imaging features include pachymeningeal gadolinium enhancement and sagging of the brain. On spinal MR images, diverticula are frequently noted. In cases in which symptoms are severe and refractory to less invasive measures, surgical intervention is indicated. Tears in the dura or leaking diverticula that are identified as the sources of the CSF leak often can be ligated or repaired. When a source of CSF egress is not found intraoperatively, packing the epidural space with blood-soaked Gelfoam or muscle at the appropriate level can lead to relief of symptoms. Occasionally the dural defect is large, irregular, or has attenuated borders that may not be possible to repair with sutures. These may be repaired by packing the defect with muscle or blood-soaked Gelfoam. Indications for and outcomes of surgery in patients with this condition will become more defined as surgeons gain experience with these procedures.
Cerebrospinal Fluid Pressure↗
Spontaneous spinal cerebrospinal fluid leaks: a review.
Spontaneous intracranial hypotension has become a well-recognized clinical entity, but it remains an uncommonly, and probably underdiagnosed, cause of headache; its estimated prevalence is only one in 50,000 individuals. The clinical spectrum of spontaneous intracranial hypotension is quite variable and includes headache, neck stiffness, cranial nerve dysfunction, radicular arm pain, and symptoms of diencephalic or hindbrain herniation. Leakage of the spinal cerebrospinal fluid (CSF) is the most common cause of spontaneous intracranial hypotension. A combination of an underlying weakness of the spinal meninges and a more or less trivial traumatic event is often found to cause this event in these patients. Typical magnetic resonance imaging findings include diffuse pachymeningeal enhancement, subdural fluid collections, and downward displacement of the brain, sometimes mimicking a Chiari I malformation. Opening pressure is often, but not always, low, and examination of CSF may reveal pleocytosis, an elevated protein count, and xanthochromia. The use of myelography computerized tomography scanning is the most reliable method for the accurate localization of the CSF leak. Most CSF leaks are found at the cervicothoracic junction or in the thoracic spine. The initial treatment of choice is a lumbar epidural blood patch, regardless of the location of the CSF leak. If the epidural blood patch fails, the blood patch procedure can be repeated at the lumbar level, or a blood patch can be directed at the exact site of the leak. Surgical repair of the CSF leak is safe and generally successful, although a distinct structural cause of the leak often is not found.
Blood Patch, Epidural↗
Chordomas and chondrosarcomas of the skull base: results and complications of surgical management.
OBJECT: Chordomas and chondrosarcomas are rare and difficult to treat tumors for which the optimum treatment modality remains controversial. The aim of this study was to evaluate the surgery-related results and complications in a series of patients in whom radical resection was the treatment of choice. METHODS: The authors conducted a retrospective analysis of the surgery-related results and complications associated with chordoma and chondrosarcoma in 64 patients of whom 33 (52%) had previously undergone some form of treatment. Total or near-total excision was achieved in 56% and this rate increased to 68% in patients without prior treatment. The main complications were postoperative cerebrospinal fluid leakage, intraoperative arterial injury, and new-onset cranial nerve deficits. Arterial injury occurred only and perioperative death occurred more often in patients who had undergone previous treatment. CONCLUSIONS: Analysis of the results provides support for a policy of radical excision of chordomas and chondrosarcomas at the time of first presentation. A higher incidence of procedure-related complications is found in patients who have already undergone surgery and radiotherapy.
Adult↗
Microendoscopic discectomy for recurrent disc herniations.
OBJECT: The use of microendoscopic discectomy (MED) for the treatment of primary lumbar disc herniations has become fairly well accepted; its role in recurrent disc herniations is less clear. The reluctance of many surgeons to use this technique stems, in part, from the concern of undertaking an endoscopic discectomy in a patient in whom the anatomy is distorted from a previous operation. It appears counterintuitive to operate through a limited working area when the traditional open approach for recurrence favors wider exposure of the surgical field. Given that operating on previously exposed tissue can be associated with even greater morbidity than on virginal tissue, the authors describe their experience with performing MED for recurrent disc herniation. METHODS: Unilateral MED was performed in patients with classic symptoms of lumbar radiculopathy, a previous operation at that level, and findings of recurrent disc herniation on magnetic resonance imaging. The approach was similar to a standard MED. Aided by fluoroscopic guidance, a working cannula was docked on the laminofacet junction at the level of the nerve root, with care taken to ensure a slightly more lateral initial trajectory. A good decompression of the nerve root could then be achieved through the use of the endoscope with preservation of the paraspinous musculature and much of the remaining facet capsule. Ten consecutive patients undergoing the procedure were analyzed prospectively and compared with the previous 25 who underwent routine single-level MED. Use of the MED technique provided excellent visualization and decompression of the nerve root; no conversions to open procedures were necessary in either group. The average operative time in the experimental group was 98.5 minutes, with a mean blood loss of 33 ml and an approximate hospital stay of 7.3 hours. In this respect, there was no statistical difference between the two groups (analysis of variance, p = 0.39, 0.68, and 0.51, respectively). There was one cerebrospinal fluid leak in each group. CONCLUSIONS: Microendoscopic discectomy for recurrent disc herniation can be safely performed without an increase in surgery related morbidity.
Adult↗
Clinical outcomes after minimal-access surgery for recurrent lumbar disc herniation.
OBJECT: Experience with minimal-access surgical approaches for revision lumbar surgery has not been previously reported. METHODS: During a 7-month period, 10 consecutive patients with recurrent disc herniations underwent revision operations in which microendoscopic discectomy (MED) was performed. Perioperative data and clinical outcomes (according to Macnab criteria) were compared with those obtained in 25 consecutive patients who underwent routine single-level MED as well as with previously published data. Overall, outcome of the MED-treated revision group was excellent or good in 90% during a mean follow-up period of 18.5 months (minimum 12 months). Operative blood loss, duration, complications, and length of hospital stay were not significantly different between the revision and primary MED-treated groups. CONCLUSIONS: Analysis of these early data suggests equivalent or superior results are obtained when performing MED compared with historical controls in which conventional surgery was conducted for recurrent disc surgery. The procedure appears to be a safe and effective alternative in cases in which recurrent lumbar disc herniation causes radiculopathy.
Adult↗