The authors treated and followed-up 11 patients with growing skull fractures during the last 10 years. Two atypical forms of these fractures, characterized by difficulties in surgical repair or failure of conventional procedure, were identified. Five patients required unconventional procedures to effect a cure. Thus, three required shunt surgery (ventriculoperitoneal, n = 2 and cystoperitoneal, n = 1) and two recurrent cases had a modified surgical procedure. This unique and useful method of repairing this defect is described as well.

Pseudomeningocele is a well known complication of foramen magnum decompression. Symptomatic subdural hygroma has not previously been described. We discuss a case of Arnold Chiari malformation type 1 in a 55-year-old Caucasian woman who underwent foramen magnum and upper cervical decompression and who developed a symptomatic subdural hygroma 2 weeks following surgery. This complication was most likely due to a technical error during surgery. It responded favourably to conservative therapy.

The unusual computed tomographic findings of an extensive intramedullary lipoma of the dorsocervical spinal cord, which extended into the brain stem, in a 9-month-old infant are described and correlated with the surgical findings. The operative therapeutic options are discussed.

Bismuth iodoform paraffin paste (BIPP) is used in dressings in ear, nose, and throat, dental, and neurosurgical practice. Neurotoxicity due to absorption of bismuth from the BIPP pack is rare. It is preventable and reversible but likely to be fatal if unrecognised. A case of relapsing but reversible toxic encephalopathy due to a large extradural BIPP pack is reported in a 57 year old Caucasian woman, operated on for a huge basal cell carcinoma of the vertex invading the skull and extradural space. Clinical, neuroradiological (CT and MRI), and biochemical studies are presented and discussed in the light of the available literature.

The first case of an intracranial epidural tuberculoma with the absence of dural and brain involvement in a 27-year-old woman is presented. The possible pathogenesis of this unique lesion is discussed.

The authors describe a case of a large subtentorial supracollicular diverticulum of the third ventricle associated with a cavernous angioma in its wall in a 6-year-old girl who presented with developmental delay and obstructive hydrocephalus. This is the first case in which such association has been diagnosed and successfully treated. The literature is reviewed, and the possible relationship between these two rare lesions is discussed.

SUMMARY: STUDY DESIGN Two cases of symptomatic epidural varices are presented and the literature was reviewed on this entity.OBJECTIVE To raise awareness of this rare condition in the interpretation of preoperative magnetic resonance imaging scans and to assess the results of surgical treatment.BACKGROUND Symptomatic epidural varices presenting with radiculopathy are extremely rare, and the diagnosis is often missed in the preoperative evaluation. This condition commonly masquerades as a herniated nucleus pulposus. Diagnosis is often only made intraoperatively.MATERIALS AND METHODS Case 1 is a 40-year-old man presenting with acute exacerbation of lower back pain associated with radiculopathy down his right lower limb. Magnetic resonance imaging showed a paracentral disc prolapse. At operation, a congested epidural vein impinging on the L5 nerve root was noted with no intervertebral foramens stenosis. Excision of the vein was performed. The second case, a 50-year-old man with previous spinal instrumentation, was admitted for acute onset of radiculopathy down his left lower limb. At operation, an epidural varix compressing on the L4 nerve root was noted. Retrospectively, features of epidural varices were noted in the preoperative magnetic resonance imaging scans. Both patients reported resolution of symptoms after surgery.RESULTS Excision was done for the first patient, and coagulative ablation was done in the second patient. Both patients had symptomatic relief and neurologic recovery on follow-up.CONCLUSION Our experience and the literature demonstrated that a favorable outcome with resolution of neurologic symptoms can often be achieved after excision or ablation of the epidural varices.

We present the rare case of a patient affected by low back pain and bilateral L5 sciatica from an L2-L3 herniation. Only 2 cases of monoradicular L5 compression in the high lumbar spine have been reported. The initial computed tomography study of the L4-L5 and L5-S1 spaces revealed no significant alterations. Magnetic resonance imaging showed a disc herniation at L2-3. The electrophysiological study confirmed clinical suspicions of L5 root involvement. A bilateral laminotomy with discectomy on both sides of the L2-3 space was performed. Pain disappeared completely after surgery. The patient remains asymptomatic 2 years after the operation.

Osteosarcomas of the pelvic bone are rare. Neurological complication of osteosarcomas in this location is also rare. Diagnosis is not always easy, and misdiagnosis may occur due to pelvic bone destruction and nerve root compression. We present two cases of pelvic osteosarcoma with lumbosacral radicular symptoms who were previously thought to have lumbosacral herniated intervertebral disc.

Cryomassage in combined treatment of 100 patients operated for discogenic neuropathy produced a pronounced vasotropic effect. The authors have determined optimal zones for cryomassage application and order of its usage with some physical factors.

STUDY DESIGN: An anatomic study of the cervical intervertebral foramina, nerve roots, and intradural rootlets performed using a surgical microscope. OBJECTIVES: To investigate the anatomy of cervical root compression, and to obtain the anatomic findings related to cervical foraminotomy for the treatment of cervical radiculopathy. SUMMARY OF BACKGROUND DATA: Cervical foraminotomy is a procedure performed frequently for the management of cervical radiculopathy. However, anatomic studies of cervical foraminotomy have not been fully elucidated. METHODS: In this study, 18 cadavers were obtained for the study of the cervical spine. All the soft tissues were dissected from the cervical spine. Thereafter, laminectomy and facetectomy were performed on C4 through T1 using a surgical microscope. The nerve roots and surrounding anatomic structures, including intervertebral discs and foramina, were exposed. In addition, the intradural rootlets and their intersegmental connections were observed. RESULTS: The shape of the intervertebral foramina approximated a funnel, the entrance zone being the most narrow part and the root sleeves conical, with their takeoff points from the central dural sac being the largest part. Therefore, compression of the nerve roots occurred at the entrance zone of the intervertebral foramina. Anteriorly, compression of the nerve roots was caused by protruding discs and osteophytes of the uncovertebral region, whereas the superior articular process, the ligamentum flavum, and the periradicular fibrous tissues affected the nerve posteriorly. The C5 nerve roots were found to exit over the middle aspect of the intervertebral disc, whereas the C6 and C7 nerve roots were found to traverse the proximal part of the disc. The C8 nerve roots had little overlap with the C7-T1 disc in the intervertebral foramen. The C6 and C7 rootlets passed two disc levels in the dural sac. Also, a high incidence of the intradural connections between the dorsal rootlets of C5, C6, and C7 segments was found. CONCLUSIONS: This study demonstrated the anatomy of the nerve roots, rootlets, and intervertebral foramina, and may aid in understanding the pathology of cervical radiculopathy. The presence of intradural connections between dorsal nerve roots and the relation between the course of the nerve root and the intervertebral disc may explain the clinical variation of symptoms resulting from-nerve root compression in the cervical spine. To perform cervical foraminotomy for cervical radiculopathy, it is necessary to understand the detailed anatomy of the intervertebral foramina thoroughly.

Several experimental and clinical studies suggest an important role of the quality and quantity of the material compressing the lumbosacral spinal cord radices in the development of cauda equina syndrome. These facts inspired the author to find out if the repair of neurological functions depends also on these factors. Clinical investigations of 81 persons (30 women and 51 men) were performed at minimum time of two years after the operation of the cauda equina discogenic syndrome. Mathematical analysis of the acquired data (chi-quadrate) revealed that so-called soft compression of neural structures (intervertebral disc hernia, sequester liber) negatively influenced the restoration of lower extremities motor functions (p = 0.01), sexual functions in men (p = 0.05) and radicular pain persistence (p = 0.01). On the other hand, the so-called hard compression (spondylosis deformans and protrusion of intervertebral disc) negatively influenced the restoration of sensitive innervation (p = 0.01) and voluntary control of urinary bladder emptying (p = 0.01).(Tab. 7, Ref. 24.)

An extremely rare case is reported of a 34-year-old man who had a drop foot due to a herniated disc between the first and second lumbar vertebrae with a monoradiculopathy of the fifth lumbar nerve root. The diagnosis was made on the basis of myelography and magnetic resonance imaging (MRI), which revealed a disc centrolateral herniation at the level between the first and second lumbar vertebrae. The patient underwent anterior discectomy and fusion with the use of iliac bone graft. Because of increasing local kyphosis and associated symptoms, a posterior TSRH instrumentation was added successfully. Postoperatively the patient had alleviation of his symptoms, and at the 6-year follow-up evaluation, he was completely symptomless. The spine surgeon should be aware of the possibility of this rare location of lower lumbar nerve root compression within the dural sac. In such a case, myelography and MRI seemed to be superior to the computed tomography scan.

STUDY DESIGN: Clinical and electrophysiologic data of compressed nerve roots were evaluated in patients with lumbar disc herniation. OBJECTIVES: To elucidate the characteristics of the nerve root with respect to preoperative neural deficit and to analyze the predictive factors for recovery of leg paralysis after posterior discectomy. SUMMARY OF BACKGROUND DATA: Prolonged paralysis due to disc herniation is reported to be a poor prognostic factor for motor recovery. In addition, an intraoperative somatosensory evoked potential change has been reported to be correlated with clinical outcome. METHODS: Among 64 patients with a lumbar disc herniation, a variety of clinical data, such as age, gender, duration of leg paralysis or leg pain, the angle of the positive straight leg raising test, and time for recovery from paralysis, were investigated. In addition, threshold, amplitude of compound muscle action potentials, and latency for 85 nerve roots were monitored before and after discectomy. Data were analyzed according to the grade of preoperative neural deficits: Grade 1, severe motor and sensory loss; Grade 2, mild motor and sensory loss; Grade 3, sensory loss only; Grade 4, no deficit (leg pain only); and Grade 5, asymptomatic control. RESULTS: The nerve root threshold before discectomy showed an increase in accordance with the severity of neural deficit. Thresholds of Grade 1 and 2 nerve roots were significantly higher than those of normal control subjects. The average amplitudes of compound muscle action potentials before discectomy in Grade 1 and 2 nerve roots were significantly lower than those of asymptomatic control nerve roots. Elongation of latency also showed a correlation with preoperative neurologic abnormality. Patients who complained of leg pain only were significantly younger, and those who showed severe motor disturbance tended to be older and to show a straight leg raising test angle similar to that of control nerve roots. Severe motor weakness for more than 6 months, a negative straight leg raising test, and age were considered to be poor prognostic factors for motor recovery. CONCLUSIONS: Findings of increased threshold, low amplitude of compound muscle action potentials, and elongated latency correlated with degree of motor weakness. Early decompression for compressed nerve root is recommended, especially in older patients with severe motor weakness presenting a negative straight leg raising test.