Vertebroplasty and Kyphoplasty in the Treatment of Malignant Vertebral Fractures

The purpose of this retrospective study was to assess the effectiveness and safety of Percutaneous Vertebroplasty and Kyphoplasty, in the treatment of pain deriving from neoplastic vertebral compression fractures (VCF). We treated 33 oncologic patients with these new techniques (2 pts with aggressive haemangiomas, 8 pts with myelomas and 23 pts with metastases) suffering from severe motion pain in the back, notwithstanding conservative treatment with medication and corset therapy, in the absence of neurological signs. In 3 selected patients we associated radiofrequency heat ablation with vertebroplasty in the treatment of metastases. The aim is to destroy tumor tissue and to thrombose the paravertebral and intravertebral venous plexus before stabilizing the vertebra.

Low-grade primary meningeal lymphoma: case report and review of the literature

Primary meningeal lymphoma is a rare occurrence. We present a case of an immunocompetent patient operated on for a fronto-parietal lesion similar to a meningioma, which the histological examination diagnosed as a mucosa-associated lymphoid tissue (MALT)-type lymphoma. She received no further post-operative treatment and after 36 months showed no evidence of disease. In a review of the literature, we identified 14 similar cases of MALT lymphoma pre-operatively diagnosed as meningioma. Recognition of this rare meningeal location of a lymphoma involving the central nervous system is useful for a proper diagnosis and adequate treatment.

Fifth ventricle: an unusual cystic lesion of the conus medullaris

STUDY DESIGN

Cystic dilatation of the fifth ventricle on its own is an extremely rare pathological event in adults whose pathogenesis is uncertain. The authors describe a personal case of 'fifth ventricle' and review the pertinent literature.

OBJECTIVE

To emphasize the importance of including the fifth ventricle in differential diagnosis of lesions of the conus medullaris to ensure proper treatment.

SETTING

Italy.

METHODS

A 30-year-old woman was referred to us for recurrent low back pain. The patient was assessed by clinical, electrophysiological (motor evoked potential, somatosensorial evoked potential and electromyography of the perineal and lower limb muscles) and urodynamic investigations as well as a magnetic resonance imaging (MRI) of the lumbar-sacral segment with and without gadolinium enhancement, subsequently extended to the entire vertebral column and brain. Follow-up consisted of periodic clinical evaluation and lumbar-sacral MRI after 1 and 2 years.

RESULTS

General physical examination, electrophysiological and urodynamic investigations were all negative, confirming the subjective nature of the patient's symptoms. Lumbar-sacral MRI demonstrated the presence of a cyst lesion containing cerebrospinal fluid (CSF), which did not enhance after gadolinium, compatible with the diagnosis of the terminal ventricle. By extending the MRI investigation to the entire vertebral column and brain, it was possible to exclude an association with other malformations of the central nervous system. Clinical and radiological follow-up confirmed the nonevolutive nature of the lesion 1 and 2 years later.

CONCLUSIONS

The lack of clinical symptoms and the stability of the radiological situation at 1 and 2 years follow-up motivated our choice of conservative treatment.

Spinal epidural abscess complicating chemotherapy in patients with leukemia

The authors reviewed the basic facts about infections that complicate chemotherapy, and found that a difference exists between those that are medically treated, for which several standard protocols have been adopted, and infections amenable to surgical treatment, such as spinal epidural abscess, which are managed according to the experience at individual institutions. The authors believe that patients with leukemia who manifest a spinal epidural abscess should always be surgically treated when the infection occurs between the induction and remission phases, whereas medical treatment options can be considered for spinal epidural abscesses occurring at the end of the chemotherapy course.

Calcifying pseudo-tumor of the spine: description of a case and review of the literature

A case of calcifying pseudo-tumor of the thoracic spine, a rare lesion with tumor-like behavior and a probable inflammatory-reactive origin, is described. The clinical-pathological and neuro-radiological aspects of this lesion are discussed in relation to surgical treatment. In accordance with the other cases reported in the literature, the case observed confirmed the benign behavior of the lesion and the effectiveness of surgical treatment for achieving complete resolution of clinical symptoms without any recurrences, even when removal is only subtotal.

Axial loading MRI of the lumbar spine

BACKGROUND

The aim of our study was to evaluate the incoming interrelations between chronic low back pain and biomechanical changes of the lumbar spine, using an MRI-compatible axial-loading device mimicking the standing position.

MATERIALS AND METHODS

Fifty consecutive patients (28 males and 22 females), with both chronic low pack pain and recurrent painful blockages, were selected and studied using a 1.5 T Gyroscan Intera Philips MRI unit (Philips, Best, Holland) and a dedicated axial loading apparatus (MIKAI manufacturing, Genoa, Italy).

RESULTS

After loading, no significant modifications occurred in ten patients (20%), a spinal stenosis was seen in 18 patients (45%), an increase in the discal protrusions or hernias was detected in 8 patients (20%) and a significant accentuation of the spondylolisthesis was observed in 6 patients (15%).

CONCLUSION

Axial loading MRI provides valuable information for specific non-invasive or operative management of low back pain.

Syringomyelia associated with hydrocephalus and Blake's pouch cyst: case report

STUDY DESIGN

This is a case report of a 37-year-old woman who sought treatment for a large syringomyelic cavitation extending from C3 to the entire medulla, a tetraventricular hydrocephalus, and a cystic cavitation in the posterior cranial fossa communicating with the fourth ventricle (Blake's pouch cyst). The patient underwent a decompressive craniectomy, a C1 laminectomy, and the opening of the cysts to enable communication with the subarachnoid spaces. After an initial period of symptom remission, reassured by the magnetic resonance images indicating a reduction of the syringomyelia, the patient's neurologic conditions deteriorated because of further dilation of the ventricular cavities, which was resolved by the insertion of a ventriculoperitoneal shunt.

OBJECTIVE

To suggest the treatment of choice in a patient with syringomyelia and hydrocephalus caused by Blake's pouch cyst.

SUMMARY OF BACKGROUND DATA

Blake's pouch cyst is an entity often poorly understood, deriving from nonperforation of the primitive foramen of Magendie, causing a precarious equilibrium of the cerebrospinal fluid flow resulting from a defect in communication between the fourth ventricle and the encephalic and spinal subarachnoid spaces. Authors report the association of Blake's pouch cyst with cervicodorsal syringomyelia and tetraventricular hydrocephalus.

METHODS

A case of syringomyelia associated with hydrocephalus and Blake's pouch cyst is described.

RESULTS

Symptoms of syringomyelia and hydrocephalus disappeared only after positioning of a ventriculoperitoneal shunt.

CONCLUSIONS

The treatment of choice for a case of syringomyelia associated with Blake's pouch cyst and hydrocephalus is the application of a ventriculoperitoneal shunt or, even better, an endoscopic third ventriculostomy.

Intrasphenoidal encephalocele associated with cerebrospinal fluid fistula and subdural hematomas: technical case report

OBJECTIVE AND IMPORTANCE

Intrasphenoidal encephalocele is a rare clinical entity that is often complicated by rhinorrhea, recurrent meningitis, and headache, but in no case has the association of rhinorrhea with subdural hematomas been described. A surgical procedure to stop persistent cerebrospinal fluid leakage is reported.

CLINICAL PRESENTATION

A 59-year-old man sought care for intractable rhinoliquorrhea of 6 months' duration. Cranial computed tomographic and magnetic resonance imaging scans revealed a basal posterior frontal bony defect and an evocative image suggesting intrasphenoidal encephalocele.

INTERVENTION

A transnasal transsphenoidal surgical procedure was performed; the encephalocele was removed, and the sphenoid sinus was filled with an inflatable pouch made of synthetic dura mater containing abdominal fat. Postoperative reduction of the rhinoliquorrhea, but not its total disappearance, was observed. Total disappearance was achieved only after endonasal, transmucosal inflation of the pouch with human fibrin glue. One of the subdural hematomas disappeared spontaneously, and the other was treated by a surgical procedure.

CONCLUSION

The possible role of the presented technique in the treatment of cerebrospinal fluid leakage is discussed.

Solitary fibrous tumor of the orbit. Case report and review of the literature

BACKGROUND

Solitary fibrous tumor (SFT), which usually presents in the pleura and is thought to be mesothelial in nature, has been recently discovered in extrapleural sites, including the orbit. Presently ultrastructural studies show absence of epithelial-mesothelial features, and reactivity of the tumor cells to CD34 antigen on immunohistochemical analysis suggests the mesenchymal origin of such tumors.

CASE DESCRIPTION

A 40-year-old woman had a 4-year history of progressive swelling of her right upper lid and a slow-growing palpable mass of the orbit. CT and MR imaging showed a well circumscribed, nonenhanced extraconal mass with mild erosion of the right orbital roof. The tumor was totally excised. Histological examination disclosed a spindle-cell tumor in a dense fibrous tissue. Immunohistochemistry showed positive staining for vimentin and CD34. We review the clinical, diagnostic, and surgical features of 22 orbital SFTs including the present case.

CONCLUSIONS

Orbital SFT generally pursues a slow, indolent, and nonaggressive course, reaches a size up to 4.5 cm, and can be cured by a single excision. It must be immunohistochemically differentiated from other spindle-cell tumors of the orbit.

Paraganglioma of the cauda equina. Case report with 33-month recurrence free follow-up and review of the literature

Paraganglioma of the cauda equina is an unusual tumor and do not have the secretory properties of the same tumors arising outside the nervous system. In none of the few cases reported in literature a preoperative diagnosis was possible, and the surgical findings raised questions in the differential diagnosis with ependymomas. A rare case of paraganglioma of the cauda equina studied both pre- and postoperatively by MRI, and treated with subtotal excision combined with radiotherapy is described. Results and recurrence rates of the cases reported in literature are reviewed. Though MRI imaging has proven to be more sensitive than other radiological procedures, we stress the difficulties of preoperative diagnosis of paragangliomas in this site. The correct diagnosis of the paraganglioma of the cauda equina still relies on immunochemistry and electron microscopy. Total excision is often very difficult owing the tendency of these neoplasms to infiltrate cauda's roots. A 33-month recurrence free follow-up of our patient confirms that successful treatment is achieved by subtotal resection combined with radiotherapy.

Computed tomography-guided transsphenoidal closure of postsurgical cerebrospinal fluid fistula: a transmucosal needle technique

BACKGROUND

Cerebrospinal fluid (CSF) fistula represents a fearful complication of transsphenoidal surgery and, despite careful intraoperative repair and prolonged postoperative lumbar CSF drainage, need for a new surgical intrasphenoidal plasty is not uncommon.

METHODS

These cases prompted us to develop a simple, minimally invasive, harmless repeatable technique consisting of a computed tomography (CT)-guided intrasphenoidal injection of fibrin glue through a 12-gauge spinal needle.

RESULTS

Five patients presenting with rhinoliquorrhea following a transsphenoidal approach for the excision of pituitary adenomas (three cases) and craniopharyngiomas (two cases) were treated successfully with the presented technique. In two cases the first attempt attained only partial success and therefore the procedure was repeated. In the last two cases, the injection of fibrin glue was preceded by 2 cc of fresh autologous blood, with the aim of enhancing the mechanisms of healing, possibly inducing adhesions and fibrosis.

CONCLUSIONS

The proposed method of treatment for CSF leakage following transsphenoidal surgery may represent a valid alternative to the surgical option.

Protective effects of nedocromil sodium on cellular and biohumoral components present in the bronchial alveolar lavage fluid and in peripheral blood in atopic asthmatics

Nedocromil sodium, a disodium salt of a pyroquinolinedicarboxylic acid, raises the bronchial hyperresponsiveness threshold, because it inhibits the mediators released by the various cells, and reduces the involvement and activation of inflammatory cells. The aim of this study was to evaluate the state of activation of the immunocompetent cells and the main chemical mediators present in the bronchoalveolar lavage (BAL) fluid from 10 atopic asthmatic patients, before and after treatment with nedocromil sodium. The following examinations were performed before treatment and after 120 days of therapy with nedocromil sodium at 16 mg/day (two 2-mg puffs x 4): the level of chemical mediators and the state of activation of immunocompetent cells in BAL fluid; immunological analytes in activation of immunocompetent cells in BAL fluid; immunological analytes in peripheral blood; aspecific bronchial challenge test with ultrasonicated bidistilled H2O fog to evaluate variations in the hyperreactivity threshold; questionnaire to determine any adverse effects of treatment (cough, breathlessness, sleep disorders). Our findings demonstrate that nedocromil sodium prevents the release of chemotactic and inflammatory mediators by the effector cells and thus stabilizes microvascular permeability and epithelial damage, so raising the threshold of response to bronchoconstriction stimuli. Lastly, nedocromil sodium is associated with a better preventive therapeutic efficacy and good tolerance and can therefore be suggested as a valid drug to be used in the long-term treatment of bronchial asthma.

The supine position for transsphenoidal surgery

The supine position has been routinely used for transphenoidal microsurgery in our department since 1973. We had 404 patients, 387 of whom had pituitary micro-or macroadenomas. It is always satisfactory, allowing a very good control of intraoperative arterial pressure and prevention of air embolism. It is also comfortable for both surgeons.

Sex steroid hormones in the pathogenesis of chronic subdural haematoma

In order to verify whether hormonal factors could be involved in the pathogenesis of Chronic Subdural Haematoma (CSDH), based on clinical and epidemiological demonstration of higher incidence of this disease in male patients and particularly in those with high urinary estrogen values, Estradiol (ER) and Progesterone (PR) Receptors were studied in the Haematoma External Membrane (HEM) in 18 male and 7 female CSDH patients. The observed higher incidence of ER and PR in male rather than in female patients (73% vs 27% and 72% vs 28% for male and female patients respectively), and the higher concentration of ER in the HEM of male rather then female patients (55 +/- 15 S.E. vs 13 +/- 7 S.E. fmol/mg protein) suggest that this pathological process, which affects individuals whose gonadal activity is quiescent, is mainly dependent upon hormonal local effect played by estrogen compounds on the HEM of the male patients. In this sex, in fact, whose tissues are not usually adapted to an estrogen action, the effect of estrogens on a responsive tissue such as the newly-vascularized HEM could lead to an increased formation of tissue Plasminogen Activator (t-PA), a compound that, escaping into the subdural collection, could maintain a local hyperfibrinolysis with formation of Fibrinogen Degradation Products (FDP). Therefore local hyperfibrinolysis enhanced by steroid hormones and the subsequent CSDH may perhaps be influenced by the prophylactic or adjuvant treatment with inhibitors either of the aromatase activity or of the estrogen action at receptor level.

Potential risk factors for brain tumors in children. An analysis of 200 cases

Two hundred cases of verified brain tumors occurring in patients under 15 years of age were studied in relation to possible etiologic, genetic, and environmental risk factors. They were compared with 100 age-matched patients harboring solid neoplasms outside the nervous system, as well as with 100 normal children. In our study, first-degree relatives of a brain tumor child did not show a higher incidence of either tumors or of epilepsy and strokes as compared with controls. First-born children (46%) with higher birth weights showed a greater tendency to present brain tumors. Dystocia (18.5%), previous miscarriages (18%), and dietary restrictions during pregnancy (3%) were also noted in this study and compared with data in the literature. No evidence of a role of maternal chickenpox and toxoplasmosis could be found. The pharmacological risk also seemed to be minimal. The mother's hormonal profile is deduced from the age at menarche and delivery, as well as from a tendency to miscarriages and complicated pregnancies. With regard to the immunologic aspect, it is worth noting that 15% of the mothers complained of allergies. Live polio vaccine and zoonosis might suggest a possible role of virus-related factors in the oncogenesis of brain tumors in children. Radiation-related risk is possibly present in less than 5% of cases. Parental occupation is not relevant in this series.

[Correlations between the prick test and aspecific bronchial reactivity in atopic patients]

Aspecific bronchial provocation test with Methacholine plays an outstanding role in the diagnostic routine of asthmatic disease, in order to accomplish a correct interpretation of the relation between A.B.I. and bronchial asthma. All researches give a special prominence to the bronchial reactivity distribution among the population, and point out that the distribution curve of response to aspecific challenge shows itself as an unimodal curve, since there is no clinic group (neither that one including subjects defined asthmatic from a clinic or anamnestic point of view) which clearly separates from the rest. A further important consideration indicates that a positive response to the test is not specific of bronchial asthmatic subjects, but it can also occur in patients affected with other pathologies such as chronic bronchitis, allergic rhinitis, and so on. Our study aimed, therefore, to evaluate the correlations occurring between skin sensitivity and aspecific bronchial reactivity in 5 groups of atopic patients (affected with: (1) asthma; (2) asthma + rhinitis; (3) asthma + rhinitis + conjunctivitis; (4) rhinitis + conjunctivitis; (5) rhinitis). In doing such correlations we also considered some other factors like sex, smoking habit, town or country provenance. Sensitiveness, specificity, and predicting value of Prick-test in comparison with Methacholine test have been analysed as well. The results so obtained show that no correlation occurs between Prick-test and Aspecific Bronchial Test in the groups of tested subjects. Test sensitiveness increases in the groups of patients affected with associated pathologies, and depends on factors like sex, smoking habit, town or country provenance.

Chronic subperiosteal hematoma of the skull in an adult: a case report

A unique case of chronic subperiosteal hematoma of the skull in an adult is reported. The possible pathogenetic mechanisms involved in the slowly progressive enlargement of the lesion are discussed.

[Cystic cervico-dorso-lumbar teratoma]

The authors describe a rare case of teratomatous cervical-dorsal-lumbar cyst. Spinal CT was of particular interest in showing lesion extension and its intramedullary and extramedullary location.

Hormones and tumours in central nervous system (CNS): steroid receptors in primary spinal cord tumours

On the basis of the studies reported on steroid receptors in brain tumours, cytoplasmic and nuclear estrogen (ER) and progesterone (PR) receptors have been examined in forty primary spinal cord tumours: fifteen neurinomas, three neurofibromas, nine meningiomas, nine ependymomas, two astrocytomas, one oligodendroglioma and one hemangiopericytoma with the exchange method in the presence of sodium thiocyanate for ER and using the synthetic progestin R5020 for PR. Regardless the type of the tumour, ER have been detected with a higher incidence in male than in female patients (78% versus 59%). PR had the same incidence in male and in female patients. The neurinoma was the oncotype more constantly provided with steroid receptors: nuclear ER, in fact, has been found with an incidence of 75% in male and of 43% in female patients. This oncotype is usually provided in both sexes with PR. Ependymomas is spinal tumour with the highest incidence of cytosol ER both in male and in female patients. On the basis of the above results reported it can be assumed that hormonal factors might be involved in the occurrence as well as in the growth of spinal cord tumours. Therefore it can be hypothesized that hormonal treatment might favourably be used as an adjuvant therapy in some selected patients with receptor positive spinal tumours.

Steroid receptors in CNS: estradiol(ER) and progesterone(PR) receptors in human spinal cord tumors

To investigate the role of steroid hormones in the occurrence and growth of human spinal cord tumors and to study the biochemical basis of the sex related difference in the incidence of the various spinal oncotypes, ER and PR have been measured in 24 human spinal cord tumors (12 neurinomas, 6 meningiomas, 5 ependymomas and 1 astrocytoma) by means of sodium thiocyanate exchange assay at low temperature and with dextran-coated charcoal method and R5020 for PR. Cytoplasmic and nuclear receptors have been evaluated. Neurinomas are the oncotypes which contained both ER (usually in the nuclear fraction) adn PR: estradiol binding has been found only in one meningioma; ependymomas contained cytoplasmic ER and the astrocytoma had nuclear ER and cytoplasmic PR. The dissociation constant is in favour of a high affinity binding (Kd = 0.15 X 10(-9)M for ERc; Kd = 3.85 X 10(-9)M for ERn; Kd = 8.07 X 10(-9)M for PRc). The overall incidence of steroid receptors in the spinal oncotypes studied is higher in male than in female patients (63.64 vs 46.15% for ER and 100 vs 71.43% for PR). Further studies on a greater number of patients will help to define the correlation between different spinal oncotypes and steroid receptors as well as the possibility of an endocrine therapy as adjuvant treatment for selected patients.