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James K. Liu, Chad D. Cole, Peter Kan and Meic H. Schmidt

✓Extradural arachnoid cysts in the spine are rare and are seldom a cause of spinal cord compression. They are thought to arise from congenital defects in the dura mater, and they almost always communicate with the intrathecal subarachnoid space through a small defect in the dura. The mainstay of treatment in patients with neurological symptoms is surgical removal of the cyst together with ligation of the communicating pedicle and closure of the dural defect. In the present paper the authors review the literature and discuss the clinical and pathological features, mechanisms of pathogenesis, neuroimaging characteristics, and surgical management of spinal extradural arachnoid cysts. The surgical technique for removal of these lesions is illustrated in a patient with a large thoracolumbar spinal extradural arachnoid cyst causing neurogenic claudication.

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James K. Liu, Chad D. Cole, Gregory T. Sherr, John R. W. Kestle and Marion L. Walker

✓Extradural arachnoid cysts in the spine are relatively uncommon causes of spinal cord compression in the pediatric population that are thought to arise from congenital defects in the dura mater. Most reports describe such cysts communicating with the intrathecal subarachnoid space through a small defect in the dura. The authors describe the case of a child who presented with spinal cord compression caused by a large spinal extradural arachnoid cyst that did not communicate with the intradural subarachnoid space. An 11-year-old girl presented with urinary urgency, progressive lower-extremity weakness, myelopathy, and severe gait ataxia. Magnetic resonance imaging of the spine demonstrated a large extradural arachnoid cyst extending from T-8 to T-12. The patient underwent a thoracic laminoplasty for en bloc resection of the spinal extradural arachnoid cyst. Intraoperatively, the dura was intact and there was no evidence of communication into the intradural subarachnoid space. Postoperatively, the patient's motor strength and ambulation improved immediately, and no subsequent cerebrospinal fluid leak occurred.

Noncommunicating spinal extradural arachnoid cysts are extremely rare lesions that can cause spinal cord compression in children. Because the dura remains intact, they can be removed entirely without subsequent dural repair. The authors review the literature and discuss the proposed underlying mechanisms of formation of these arachnoid cysts.

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James K. Liu, Chad D. Cole, John R. W. Kestle, Douglas L. Brockmeyer and Marion L. Walker

The optimal treatment of craniopharyngioma in children remains a challenge. The use of complete excision to minimize recurrence continues to be controversial because of the risk of postoperative morbidity and death. Advances in skull base approaches, modern microsurgical techniques, neuroimaging, and hormone replacement therapy, however, have allowed safe gross- or near-total resection in the majority of cases. Total removal of these tumors, if possible, offers the best chance of cure for the patient. Although craniopharyngiomas are not strictly tumors of skull base origin, their intimate relationship with the neurovascular structures of this region often requires a skull base approach to maximize the surgical corridor and facilitate adequate microsurgical resection. In this review, the authors focus on commonly used skull base approaches for the surgical management of craniopharyngioma. They discuss the relative indications, advantages, disadvantages, and complications associated with each approach. Illustrative cases and intra-operative videos are presented.

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Chad D. Cole, James K. Liu and Ronald I. Apfelbaum

Since the earliest recorded history of medicine, physicians have been challenged by the difficulty in relieving the great pain experienced by individuals suffering from trigeminal neuralgia (TN). The nature of the pain and the events that incite it have been well described, but effective treatments with acceptable levels of side effects remained elusive until the latter part of the 20th century. As a result, many theories about the origins of TN have been proposed, along with numerous treatment modalities. The pathophysiological causes of TN remain incompletely understood, but the medical and surgical treatment techniques currently used offer effective ways to relieve this extremely painful condition. In this historical review the authors discuss the initial descriptions of tic douloureux, Fothergill disease, and TN, along with various therapeutic interventions and their refinements.

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Chad D. Cole, Oren N. Gottfried, James K. Liu and William T. Couldwell

Hyponatremia is frequently encountered in patients who have undergone neurosurgery for intracranial processes. Making an accurate diagnosis between the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and cerebral salt wasting (CSW) in patients in whom hyponatremia develops is important because treatment differs greatly between the conditions. The SIADH is a volume-expanded condition, whereas CSW is a volume-contracted state that involves renal loss of sodium. Treatment for patients with SIADH is fluid restriction and treatment for patients with CSW is generally salt and water replacement. In this review, the authors discuss the differential diagnosis of hyponatremia, distinguish SIADH from CSW, and highlight the diagnosis and management of hyponatremia, which is commonly encountered in patients who have undergone neurosurgery, specifically those with traumatic brain injury, aneurysmal subarachnoid hemorrhage, recent transsphenoidal surgery for pituitary tumors, and postoperative cranial vault reconstruction for craniosynostosis.

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James K. Liu, Oren N. Gottfried, Chad D. Cole, William R. Dougherty and William T. Couldwell

Object

Cranial reconstruction after skull base surgery is important for restoration of function and cosmesis. The authors describe their experience with the Medpor porous polyethylene implant for cosmetic cranioplasty and reconstruction after skull base surgery.

Methods

Medpor, a biocompatible implant, is flexible and can be contoured to facilitate surgical reconstruction of small to medium (< 8 cm) convexity or cranial base defects resulting from a variety of skull base approaches. This method provides similar cosmetic results to standard alloplast cranioplasty while decreasing operating time. The porous nature of the material allows ingrowth of soft tissue and bone to increase implant strength and decrease the risk of infection. This material can also be used safely in reconstruction of the cranium and skull base adjacent to the paranasal sinuses.

Conclusions

The authors have used the Medpor porous polyethylene implant in 611 standard cranial and skull base procedures and have achieved excellent cosmetic results and no implant-related complications.