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Syringomyelia associated with foramen magnum arachnoiditis

Jörg Klekamp, Giorgio Iaconetta, Ulrich Batzdorf, and Madjid Samii

Object. Syringomyelia is often linked to pathological lesions of the foramen magnum. The most common cause is hindbrain herniation, usually referred to as Chiari I or II malformation. Foramen magnum arachnoiditis without either Chiari I or II malformation is a rare cause of syringomyelia. The authors undertook a retrospective analysis of 21 patients with foramen magnum arachnoiditis (FMA) and syringomyelia treated between 1978 and 2000 to determine clinical course and optimum management.

Methods. In the review of records, 21 patients with FMA and syringomyelia were documented. A stable clinical course was demonstrated in three patients in whom surgery was not performed, and one patient refused surgical intervention. Seventeen patients underwent 23 operations to treat progressive neurological disease. Of these 23 operations, 18 involved opening of the foramen magnum, arachnoid dissection, and placement of a large dural graft. One patient underwent insertion of a ventriculoperitoneal shunt for treatment of accompanying hydrocephalus, one patient received a cystoperitoneal shunt for an accompanying arachnoid cyst; two syringoperitoneal and one syringosubarachnoid shunts were also inserted. Hospital and outpatient files, neuroimaging studies, and intraoperative photographic and video material were analyzed. Additional follow-up information was obtained by telephone interview and questionnaires.

Standard and cardiac-gated magnetic resonance imaging studies are the diagnostic procedures of choice in these patients. Sensory disturbances, dysesthesias, and pain were the only symptoms likely to improve after foramen magnum surgery. Motor weakness and gait disturbances, which were severe in a considerable number of patients, and swallowing disorders tended to remain unchanged. As a consequence of the rather severe arachnoid lesions in most patients, clinical recurrences were observed in 57% over a 5-year period.

Conclusions. Surgery for FMA and syringomyelia has to provide clear cerebrospinal fluid pathways between the cerebellopontine cisterns, spinal canal, and fourth ventricle. If this can be achieved successfully, the syrinx decreases in size and the clinical course of the patient may even improve. In patients with severe and widespread areas of arachnoiditis, however, multiple operations may be required at least to stabilize the clinical course.

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Monitoring of blood parameters following anterior cervical fusion

Steffen K. Rosahl, Alireza Gharabaghi, Peter-Michael Zink, and Madjid Samii

Object. Both C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR) were measured prospectively in 51 cases in which uncomplicated cervical anterior fusion was performed. The object of the authors was to quantify the differences in the responses of these parameters recorded in the immediate postoperative period and to determine factors influencing their course.

Methods. Nineteen one-level, 23 two-level, and nine three-level procedures for disc herniation and degenerative disease of the cervical spine were performed in 22 female and 29 male patients (mean age 49.2 years).

Blood samples were obtained 1 day before as well as on 10 consecutive days and 3 months following anterior cervical fusion. Serum CRP level was measured using a fluorescence polarization immunoassay and ESR was determined from the same samples. Operative time, the number of blood transfusions, and drugs administered in the postoperative period were recorded. In addition, hemoglobin, hematocrit, red blood cell count, platelet count, white cell count, and axillary body temperature were checked daily.

Conclusions. Monitoring of CRP level is superior to that of ESR for early detection of infections after cervical spine surgery. Although CRP was not related to any of the factors that have been proposed to explain its peak value variance in previous studies, individual acute-phase protein metabolism response to tissue affection appears to be a more decisive element in this respect.

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Congenital arthrogryposis associated with atlantoaxial subluxation and dysraphic abnormalities

Case report

Wolf O. Luedemann, Marcos S. Tatagiba, Sami Hussein, and Madjid Samii

✓ The authors report the case of a 27-year-old woman with an arthrogryposis multiplex congenita (AMC) associated with atlantoaxial subluxation. To the authors' knowledge, this is the first report of its kind. The authors review the literature with reference to dysraphic abnormalities associated with atlantoaxial subluxation and with AMC. The patient presented with severe tetraparesis following a minor traffic accident. She underwent a procedure in which transoral decompression and dorsal stabilization were performed and, postoperatively, made a good clinical outcome. The authors stress the need for diagnostic neuroimaging of the craniocervical junction in patients with AMC.

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Neurenteric cyst of the craniocervical junction

Report of three cases

Flavio Leitao Filho, Marcos Tatagiba, Gustavo A. Carvalho, Wiebke Weichhold, Jörg Klekamp, and Madjid Samii

✓ Neurenteric cysts of the craniocervical junction (CCJ) are very rare lesions. Their origin is the subject of long-standing controversy, but a failure during the embryogenic phase may be responsible for their formation. Accurate histopathological diagnosis may be difficult due to the similarity they share with other cystic lesions such as colloidal cysts, Rathke cysts, and cystic teratomas. Surgical removal is the treatment of choice for intracranial neurenteric cysts, but in some cases, infiltration of the surrounding structures may hinder complete resection. Three cases of neurenteric cysts located at the CCJ are reported.