Spontaneous CSF leaks: A paradigm for definitive repair and management of intracranial hypertension

OBJECTIVE: To report our outcomes with the repair of spontaneous cerebrospinal fluid (CSF) leaks and to demonstrate how management of underlying intracranial hypertension improves outcomes. STUDY DESIGN: Retrospective review of spontaneous CSF leaks treated at the University of Pennsylvania Health System from 1996 to 2006. Data collected included demographics, nature of presentation, body mass index (BMI), site of skull base defect, surgical approach, intracranial pressure, and clinical follow-up. RESULTS: Fifty-six patients underwent repair of spontaneous CSF leaks. Eighty-two percent (46 of 56) were obese (average BMI 36.2 kg/m(2)). Nine patients had multiple CSF leaks. Fifty-four patients (96%) had associated encephaloceles. Fifty-three CSF leaks (95%) were successfully repaired at first attempt (34 months of follow-up). Intracranial pressures averaged 27 cm H(2)O. Patients were treated with acetazolamide or, in severe cases, with a ventriculoperitoneal shunt. CONCLUSIONS: Spontaneous CSF leaks have the highest recurrence rate of any etiology. With treatment of underlying intracranial hypertension coupled with endoscopic repair, the success rate (95%) approaches that of other etiologies of CSF leaks.     

Transradicular interfascicular approach for lumbar microdiscectomy: a useful technique in difficult circumstances

Nerve root retraction is a component of lumbar disc surgery. The authors describe a transdural approach for lumbar microdiscectomy through the nerve root, instead of retracting the root. This technique can be safely used in rare cases where root manipulation is considered to be difficult and dangerous.     

Endoscopic sphincterotomy is a useful preoperative management for refractory pancreatitis associated with pancreaticobiliary maljunction

Background

Pancreatitis associated with pancreaticobiliary maljunction (PBM) is commonly treated nonoperatively before surgery. It is, however, sometimes uncontrollable, and little has been reported about the management.

Methods

Focusing on the preoperative management, we reviewed clinical courses of 4 PBM cases (ages 1 to 7 years old). Each had pancreatitis that was totally resistant to medical treatment and was applied endoscopic sphincterotomy (ES).

Results

The first case underwent percutaneous transhepatic catheter drainage (PTCD) primarily. In spite of daily lavage using the drainage tube for a week, plugs located in the common channel were not removed, and clinical findings were not improved. Therefore, ES followed by removal of protein plugs was performed to improve pancreatitis dramatically. Through this experience, 3 subsequent cases with refractory pancreatitis all underwent successful ES primarily soon after the medical treatments turned out to be ineffective. In all 4 cases, protein plugs were impacted in common channels, and ES could successfully remove the plugs that were impossible to remove by using PTCD. Improved preoperative pancreaticobiliary decompression by ES shortens the duration of recalcitrant acute pancreatitis associated with PBM allowing for a subsequent safe operation.

Conclusions

Endoscopic sphincterotomy is one of the useful preoperative managements for refractory pancreatitis associated with PBM.     

Prolonged Jackson-Pratt drainage in the management of lumbar cerebrospinal fluid leaks

BACKGROUND: Cerebrospinal fluid (CSF) leak is a complication of spinal surgery. Intraoperative or postoperative identification of a CSF leak often results in wound healing complications, lumbar drain placement, and/or reoperation. These complications usually extend a patient's hospital stay, can be painful, and have their own associated risks. The authors describe a technique that may improve on traditional interventions by managing postoperative CSF leaks after lumbar instrumentation without an additional procedure or extended hospitalization. METHODS: A retrospective review of lumbar instrumentation cases performed by 5 attending surgeons from the Division of Neurosurgery, University of California at San Diego, was performed. In all, 184 charts were reviewed, spanning a 3-year period. There were 16 cases in which a dural tear and repair were carried out and subsequently treated with subfascial Jackson-Pratt (JP) drainage. Of those 16 cases, 8 patients were managed with prolonged JP drainage using the intraoperatively placed subfascial drain. Patients were discharged home on oral antibiotics according to the customary criteria with the JP drain in place and were instructed regarding proper drain maintenance. Jackson-Pratt drains were removed in clinic in a delayed fashion, approximately 10 to 17 days postoperatively. Patients were subsequently reevaluated at regular intervals for any persistent CSF leak. RESULTS: In the 8 cases reviewed, all patients were discharged in a time frame comparable to that of patients undergoing similar instrumentation in which no CSF leak was identified, or in whom a CSF leak was identified and repaired intraoperatively. No patients suffered complications arising from prolonged drain presence. No patients suffered from persistent CSF leak after drains were removed. CONCLUSION: Our study suggests that routine intraoperative subfascial JP drain placement aids in the early diagnosis of postoperative lumbar CSF leak. Primary closure of dural tear remains the standard of care. Furthermore, in select cases, prolonged JP drainage in the setting of postoperative CSF leak may be a useful technique for the treatment of these leaks.     

ISIS scanning: a useful assessment technique in the management of scoliosis

The value of surface topographical measurements in the assessment of curve progression in adolescent idiopathic scoliosis is demonstrated in a group of 51 patients. Cobb angles at the commencement of the study ranged from 10 degrees -55 degrees (mean 34.5 degrees), and the mean follow-up period was greater than 2 years. The surface shape method correctly identified curve evolution in 84% of the patient group. Of these, the eight patients who underwent spinal instrumentation were correctly predicted as candidates for surgery.     

Common sheath reimplantation with ureteral plication: A useful technique for the management of ectopic ureterocele

BACKGROUND: When salvaging the upper pole kidney in duplex ectopic ureterocele, primary bladder level surgery with common sheath ureteral reimplantation has the definite advantage of allowing the reconstruction of the entire collecting system through a single lower abdominal incision. However, there are several complications associated with a common sheath reimplantation in a child with a very dilated upper pole ureter, such as vesicoureteral reflux or ureterovesical stenosis. METHODS/RESULTS: To avoid these complications, ureteral plication over the common ureteral sheath in two children with duplex ectopic ureterocele was used. Postoperatively, neither child showed reflux or recurrent urinary tract infection and both showed a marked improvement of the upper pole collecting system. CONCLUSION: This technique allows for a simple and definitive reconstruction in cases of duplex ectopic ureterocele, particularly with dilated upper pole ureter.     

腰大池置管间断引流鞘内注射抗生素治疗胸腰椎术后脑脊液漏伴颅内感染

<正>硬膜损伤致脑脊液漏是胸腰椎手术最常见的并发症之一,发生率为2.31%~9.37%~([1~3])。但硬膜损伤后脑脊液漏继发颅内感染的报道尚不多见,一旦发生,常规静脉应用抗生素治疗效果差,死亡率高。我院自2009年2月~2014年3月在静脉应用抗生素的基础上,采用腰大池置管间断引流联合鞘内注射抗生素治疗胸腰椎术后脑脊液漏伴颅内感染患者共6例,疗效满意,总结如下。临床资料6例患者中男2例,女4例;年龄61.5±11.5(51~72岁)。腰椎间盘突出症术后4例,胸椎间盘突出     

Costs of home assistance for peritoneal dialysis: results of a European survey

Assisted peritoneal dialysis (aPD) was 'invented' in France in 1977 and was immediately very well reimbursed. This has since helped to maintain a high French peritoneal dialysis (PD) penetration rate among elderly dependent patients who might enjoy a better quality of life by remaining in their own environment. The aim of this study was to investigate the present status of aPD funding in European countries through a questionnaire sent in 2006 to health authorities and commercial PD providers asking about reimbursement modalities (in euro ([euro]) per patient per year) for nurse aPD. Specific funding for aPD only exists in Belgium, Denmark, France, Switzerland, and one region of Spain (Canary Islands). Germany and the United Kingdom are testing pilot schemes. Compared to France, all other countries exhibit significant differences in reimbursement for similar services (performing bag exchanges or disconnections from/to a cycler, exit site care, monitoring weight as well as blood pressure and ultrafiltration, and also including transportation costs) both for continuous ambulatory peritoneal dialysis (CAPD) (23 400 vs 7280 \[euro] per patient per year in Spain) and automated peritoneal dialysis (APD) (18 200 vs 5356 euro per patient per year in Belgium); these differences are difficult to understand and might reflect disparities in cost of living, national health-care budget, and/or mean nurses' salaries. Also, there is no correlation between these rates and the reimbursement for PD therapy itself. Only France and Belgium differentiate assisted CAPD and APD, but these differences do not reflect the time really spent at the patient's home. It is concluded that high reimbursement rates for assistance add significant extra cost to PD, but allow granting many dependent patients all the advantages of home therapy, instead of treating them with in-center hemodialysis which in any case still remains more expensive for our societies.     

Ileocecocystoplasty for the management of refractory neurogenic bladder: surgical technique and urodynamic findings

A total of 21 incontinent adults with a neurogenic bladder who were refractory to conservative management underwent a modified technique of ileocecocystoplasty. Followup ranged from 1 to 6 years (mean 3.1 years). To ensure a wide anastomosis the augmentation was accomplished by suturing a detubularized ileocecal patch to a large posterior based bladder flap anchored to the psoas muscles. Postoperatively 20 of 21 patients were continent. The remaining woman was cured after surgical correction of sphincteric incontinence. Mean bladder capacity increased from 185 +/- 17 to 595 +/- 43 ml. (standard error). Mean maximum detrusor pressure decreased from 53 +/- 6.3 to 16 +/- 2.3 cm. water (p less than 0.0001). Followup revealed a persistently large capacity, low pressure reservoir in all patients. No patient required anticholinergic medication. None experienced acid-base imbalance, tumors in the augmented bladder or upper tract deterioration. We conclude that this technique of ileocecocystoplasty is suitable for the management of patients with a refractory neurogenic bladder.     

The use of peritoneal venous shunting for intractable neonatal ascites: a short case series

Introduction

Intractable ascites in neonates has a varied etiology; and often, the cause is idiopathic. The management usually consists of observation, diuretics, paracentesis, albumin replacements, and self correction. However, in some cases, the above treatment remains unsuccessful.

Results

We present 2 cases of intractable ascites causing metabolic abnormalities, severe protein and immunoglobulin loss, and respiratory compromise. Although the use of peritoneovenous shunts for intractable ascites has been reported previously, our cases differ in both technique and patient size. Our first patient is an ex-28-week premature, 1.4-kg infant with intractable ascites for which a peritoneal drain was initially placed. After 3 weeks and putting out nearly 300 mL of ascitic fluid daily, we placed a peritoneal venous shunt attached to a Medtronic pump. A 6.6F Broviac was placed through the Internal Jugular. The Medtronic pump was placed subcutaneously on the right chest. The pump was compressed 5 to 10 times every 8 hours, keeping fluid actively being infused from the belly to the vascular system. The second patient was 5 months old, 2.8 kg, with a course complicated by necrotizing enterocolitis, prolonged total parenteral nutrition, and progressive liver failure and underwent the same procedure. Both patients had dramatic responses to the shunting postoperatively, with clinical, radiographic, and laboratory evidence of resolution of the ascites. The first patient had the shunt removed at 6 months of age and continues to do well, whereas our second patient had no recurrence of the ascites, but died about 1 year later from cardiopulmonary complications.

Conclusion

These 2 cases demonstrate that peritoneovenous shunting, with the assistance of a Medtronic pump, is an effective treatment of intractable neonatal ascites and should be considered early in the course before complications develop.     

Lumbar plexus blockade with ropivacaine for postoperative pain management in elderly patients undergoing urologic surgeries

BACKGROUND/AIMS: We evaluated the effectiveness and safety of lumbar plexus blockade with ropivacaine for postoperative pain relief in elderly patients undergoing flank incision for urological surgery. METHODS: 60 urological patients (>65 years old) were chosen randomly for paravertebral lumbar blockade. Postoperatively ropivacaine was used in group I (n = 30) and bupivacaine was administered in group II (n = 30) for lumbar plexus blockade. Heart rates, systolic and diastolic blood pressures, peripheral oxygen saturations, analgesia levels with visual analogue scales (VAS) were measured postoperatively at 5 and 30 min and 1, 3, 6, 8,and 12 h. Patient satisfaction scores and complications were recorded. RESULTS: The hemodynamic parameters of the groups were in the normal ranges (p > 0.05). VAS were significantly decreased at 60 min in both groups (p < 0.05) and no important increase was observed during the first 8 h (p > 0.05). After the 8-hour measurement, analgesic was given to 7 patients in group I and 6 patients in group II (p < 0.05). There were no complications (p > 0.05). Patient satisfaction scores were found to be higher for all patients (p > 0.05). CONCLUSION: In elderly patients, lumbar plexus blockade with ropivacaine can be a simple, safe and effective analgesic technique especially in the early postoperative period after urologic surgeries with flank incision.     

病灶清除椎间植骨内固定治疗腰椎术后感染

自2000年8月～2002年8月，对收治腰椎间盘术后椎间隙感染的病例13例，采用后路病灶清除、Ⅰ期椎间植骨加内固定的手术治疗，取得满意效果，现报告如下。     

Refractory abdominal-cutaneous fistulas or leaks: percutaneous management with a collagen plug

BACKGROUND: We report the results of abdominal-cutaneous fistula tract occlusion with a collagen plug in a series of patients with fistulas or leaks refractory to conservative therapy. STUDY DESIGN: Seven patients were found to have persistent fistula or leak after percutaneous drainage of abdominal pelvic fluid collections. All patients but one were refractory to surgical or percutaneous drainage. Under fluoroscopic guidance, modified Vasoseal (Datascope Inc, Montvale, NJ) collagen plugs were deployed into the fistulas using catheter-directed techniques. The plugs were split longitudinally to fit into an 8F or 9F peel-away sheath, placed into the fistula, and deployed. Results were tabulated and patients were followed up. RESULTS: Six of seven patients undergoing fluoroscopically guided, catheter-directed tract occlusion had resolution of the fistula, with no evidence of fistula or abscess recurrence from 30 to 180 days after closure. There were no procedural complications. The technique was unsuccessful in dosing a gastrocutaneous fistula after removal of a large-bore gastrostomy tube; this failure was believed to be secondary to the short length and large caliber of the tract in a patient with hypercortisolemia. CONCLUSIONS: Closure of abdominal-cutaneous fistula tracts by occlusion with a modified Vasoseal collagen plug shows promise in the management of fistulas refractory to catheter drainage.     

Cubital tunnel release with endoscopic assistance: results of a new technique

We evaluated the results of cubital tunnel release with endoscopic assistance. The study included 76 patients (85 elbows); 47 women and 29 men. Nine patients had bilateral procedures. Patients were excluded if they had less than 1 year of follow-up, associated pathology at the elbow to account for the nerve compression, or recurrent cubital tunnel syndrome. Before surgery, cases were categorized by stage of cubital tunnel syndrome according to Dellon's classification: 33 (39%) elbows were classified as mild, 35 (41%) moderate, and 17 (20%) severe. Surgical results were assessed according to a modified Bishop rating system. The mean follow-up period was 32 months (range, 12-52 months). Results were excellent in 42% of the elbows, good in 45%, fair in 11%, and poor in 2%. Recurrence occurred in 3 elbows. There were no serious complications. The results of this study support our recommendation of cubital tunnel release with endoscopic assistance as a safe and reliable technique for the treatment of cubital tunnel syndrome, especially in patients with mild to moderate symptoms.