Treatment of Calcified Lumbar Disc Herniation by Intervertebral Foramen Remolding a Retrospective Study

Background: The percutaneous intervertebral foramen mirror technology is a new solution for lumbar disorders. However, like other minimally-invasive treatments for calcified lumbar discs, it is still controversial. The aim of this study was to investigate the use of the percutaneous intervertebral foramen lens technology for secondary molding of the intervertebral foramen in the treatment of calcified lumbar discs. Methods: The study included 50 patients aged (mean ± standard deviation) 49.9 ± 14.5 years, 30 (60%) females, who were diagnosed with calcified lumbar disc herniation by computed tomography and magnetic resonance imaging. Patients underwent a percutaneous endoscopic lumbar discectomy surgery in our hospital from January 1, 2017 to December 31, 2019. Demographic characteristics before the surgery and perioperative outcomes were retrospective reviewed. The treatment outcome was analyzed using the visual analog scale (VAS) score, the Oswestry Disability Index score, and modified Macnab criteria. Results: We evaluated those patients who showed significant improvement in both the VAS and ODI scores after the surgery and maintained relatively low ODI and VAS scores during subsequent follow-ups. Ninety-four percent of patients rated the results as "excellent" or "good" according to the modified Macnab criteria at the 3-month follow-up. One patient developed neck pain during the surgery, which was diagnosed as spinal hypertension syndrome, and the surgery was suspended until the patient improved. No patient had a dural leak, infection, or other related complications. Conclusions: Our results indicate that transforaminal remolding is effective in the treatment of calcified lumbar disc herniations, with few intraoperative and postoperative complications.Our results indicate that secondary reconstruction of the intervertebral foramen under visual conditions using microscopic knife is an effective method for treating calcified lumbar disc herniation, with few intraoperative and postoperative complications.

Superficial siderosis associated with an iatrogenic posterior fossa dural leak identified on CT cisternography

Superficial siderosis refers to hemosiderin deposition along the pial surface of the brain and spinal cord. It results from chronic and repetitive low-grade bleeding into the subarachnoid space. Dural tears are a common cause of superficial siderosis. Although such tears typically occur in the spine, dural tears can also occur in the posterior fossa. In many cases, posterior fossa dural tears are iatrogenic, and patients may present with neuroimaging evidence of postoperative pseudomeningoceles. We present a case of superficial siderosis caused by a persistent posterior fossa dural leak. The patient presented with superficial siderosis 30 years after a Chiari I malformation repair. A pinhole-sized dural tear was identified preoperatively using computed tomography cisternography. The dural defect was successfully repaired. An additional small tear that was not seen on imaging was also identified at surgery and successfully repaired.

Cranial cerebrospinal fluid leak and intracranial hypotension syndrome – a case report

Spontaneous intracranial hypotension is a rare clinical entity caused in most cases by a cerebrospinal fluid leak occurring at the level of the spinal cord. Cranial dural leaks have been previously reported as a cause of orthostatic headaches but, as opposed to spinal dural leaks, were not associated with other findings characteristic of spontaneous intracranial hypotension. We present the case of a male admitted for severe orthostatic headache. The patient had a history of intermittent postural headaches, dizziness, and symptoms consistent with post-nasal drip, which appeared several years after head trauma. Brain imaging showed signs consistent with intracranial hypotension: bilateral hygromas, subarachnoid hemorrhage, superficial siderosis, diffuse contrast enhancement of the pachymeninges, and superior sagittal sinus engorgement. No spinal leak could be identified by magnetic resonance imaging, and the patient had a rapid remission of symptoms with conservative management. Further work-up identified an old temporal bone fracture which created a route of egress between the posterior fossa and the mastoid cells. Otorhinolaryngology examination showed pulsatile bloody discharge and liquorrhea at the level of the left pharyngeal opening of the Eustachian tube. The orthostatic character of the headache, as well as the brain imaging findings, were consistent with intracranial hypotension syndrome caused by a cranial dural leak. Clinical signs and imaging findings consistent with the diagnosis of apparently “spontaneous” intracranial hypotension should prompt the search for a cranial dural leak if a spinal leak is not identified.

Headache due to Bilateral Subacute Subdural Hematomas following Intracranial Hypotension Caused by Cervical Disc Herniation

Spontaneous intracranial hypotension (SIH) is caused by spinal leakage of cerebrospinal fluid (CSF) and typically causes orthostatic headache which is relieved by lying in a recumbent position. We describe the case of a 44-year-old male suffering from orthostatic headaches accompanied by symptomatic cervical disc herniation, for which he had an anterior cervical discectomy and fusion (ACDF). Computerized tomography of the brain at the emergency department 1 week after this procedure showed bilateral subacute subdural hematomas. In retrospect, the positional headache had been present for 3 months prior to the ACDF, and magnetic resonance imaging of the cervical spine prior to the ACDF already showed signs of an extradural CSF collection indicating intracranial hypotension. This case highlights the possibility of SIH caused by a spinal dural leak due to cervical disc herniation.

The algorithm for diagnosis and management of intracranial hypotension with coma: Report of two cases

Background: Spontaneous intracranial hypotension (SIH) is caused by spontaneous cerebrospinal fluid (CSF) leaks that can be treated in most cases with an epidural blood patch (EBP). However, some patients, who develop severe brain sagging, can neurologically deteriorate, and in occasional instances, which become comatose. Here, with the presentation of two cases, and a review of the literature, we have set guidelines for diagnosing SIH along with recommendations for its management. Case Description: We reviewed two cases of SIH. Both patients became comatose due to a CSF leak associated with a tear in the spinal dura diagnosed on myelo-CT studies. As targeted EBP failed to achieve sustained improvement, direct operative repair of the dural tears was warranted (video presentation). Conclusion: After reviewing two cases of SIH and the literature, we developed an algorithm for the diagnosis and management of SIH. To avoid deterioration to a comatose status, we recommend the early performance of myelo- CT studies to identify the location of the dural leak, followed by early dural repair.