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ObjectivesFalls from standing are an important cause of vertebral fractures, particularly in the elderly. They are associated with significant morbidity and long-term mortality. The aim of this study was to determine the treatment and outcomes, in a single centre, of managing spinal fractures due to falls from standing height.DesignRetrospective case note review of patients with a fracture sustained due to a fall from standing (2011–2016 inclusive).Subjects229 patients with average age 76.6±14.5 years; 134 (58.5%) female.MethodsPatients were identified from the Trauma Audit and Research Network database. Case notes were reviewed for demographics, treatment details and outcome at 6 months post-admission.Results1408 patients were admitted with spinal fractures of which 229 (16.3%) sustained a fall from standing height. Two hundred and eighty-three fractures were identified in the 229 patients, which were distributed in the cervical (n=140), thoracic (n=65) and lumbar (n=78) spine. The average ISS score was 9.7±5.4. Twenty-three (10.0%) patients had either incomplete or complete spinal cord injury. Fifty-six (24.5%) patients underwent surgical intervention. Forty-three patients (18.7%) died within 6 months and increasing age and Charlson co-morbidity score were associated with higher mortality.ConclusionsFalls from standing comprise a large portion of the spinal service emergency workload. They are associated with a high 6 month mortality similar to other fragility fractures experienced by the elderly.

ObjectivesEvaluation of the presentation, demographics, pathology and outcomes associated with surgical management of spinal meningiomas and review of an association with a history of preceding breast carcinoma.DesignA retrospective single-centre case series of surgically managed meningiomas over a 4 year period.Subjects184 cases of surgically managed intradural lesions from 2014 to 2018.Results48 patients were identified as having a spinal meningioma [26% of all spinal tumours]. 42 [88%] were female with a cumulative mean age of 69 years [SD ±10]. Most lesions were located in the thoracic spine [n=41]. The cohort had a Charlson comorbidity index of 3. Weakness [median MRC grade 3], neuropathic pain [mean NPS of 26/100] and problems with gait [median mJOA score of 2] were the commonest presenting symptoms. Post-operatively improvements in MRC, NPS, mJOA and SF36 scores were observed. 16% [n=7] of cases had a preceding history of oestrogen-receptor positive breast carcinoma, with a mean interval time between diagnoses of 8.1 years [SD ±5.1]. Risk analysis using baseline data from national cancer registries demonstrates that the likelihood of both diagnoses to be 4.9%, this is considerably lower than the observed 16% (p=0.01).ConclusionsAnalysis of our cohort has demonstrated an association between a preceding diagnosis of oestrogen-receptor positive breast carcinoma and spinal meningiomas that cannot be explained by chance alone.

ObjectivesEvaluation of the presentation, demographics, pathology and outcomes associated with the surgical management of spinal cavernous malformations [sCM].DesignA retrospective single-centre case series of surgically managed cavernous malformations over a 3 year period.SubjectsTen patients were identified to have a diagnosis of sCM.MethodsCases were identified from electronic and theatre records at a single centre. All patients underwent pre-operative assessment and radiographic evaluation.Results10 patients with a mean age of 52.6 years [SD ±14.1] and a male to female ratio of 1:1 with a mean follow-up of 14.1 months [SD ±7.9] were identified. Spinal CM spanned two vertebral levels in 9 out 10 cases with 3 cervical, 1 cervico-thoracic and 6 within the thoracic region. Duration of the symptoms prior to surgical intervention was 17 months [SD ±24], with three cases presenting with an acute [ConclusionsIn selected cases surgical management of sCM is associated with improvement in motor and sensory function postoperatively.

A 58-year-old man presented with a two-and-a-half year history of painful left L2 to S1 radiculopathy and progressively worsening left quadriceps weakness. On examination he had grade three power i...

The course of the internal carotid artery (ICA), particularly the C4–C6 segments, cavernous, clinoid, and ophthalmic, respectively, as described by Bouthillier et al. traverses a relatively compact region of complex anatomical relationships. The bony, dural, connective tissue, and neurovascular elements of this region frequently deter access or “block” surgical entry. The key to unlocking this region is a detailed understanding of its surgical anatomy. The treatment of aneurysms in proximity to the distal dural ring (DDR), e.g. clinoid, superior hypophyseal, or carotid ophthalmic aneurysms, presents considerable challenges to the neurosurgeon. The anterior clinoid process (ACP) and its associated anatomical variations, including a prominent middle clinoid process (MCP) and aerated optic strut, must be considered and anticipated when performing an anterior clinoidectomy. Aneurysms of the C4–C6 segments can transgress either the proximal or distal dural rings or both; this transgression (so-called transitional aneurysms) can occur in either direction making an extradural aneurysm and also intradural or vice versa. The existence of a carotid cave as originally described by Kobayashi et al. must be taken into consideration in the analysis of aneurysms of the ICA in proximity to the DDR. Again, determination of the relationship of the aneurysm to the DDR is critical to the decision making process; extradural aneurysms have a considerably different prognosis and treatment than intradural aneurysms. The correlation of cadaveric anatomy to surgical anatomy will serve as a guide to improve surgical techniques, strategies, and outcome.

Background Juxtafacet spinal cysts are cystic synovial lesions that often are indistinguishable clinically or radiologically and require histopathology analysis to confirm the diagnosis. Lumbar synovial cysts usually arising from the synovium of the facet joints. They have been described posterolaterally or rarely in the posterior midline. However, we describe the first synovial cyst ventral to the dural sac. Case Description We report a lumbar 3–4 lesion causing cauda equina compression in a 57-year-old man who presented with a 3-month history of low back pain and bilateral sciatica, intermittent urinary incontinence, and erectile dysfunction. Preoperative magnetic resonance imaging suggested prolapsed disc, after decompression, histological analysis of the fragment confirmed a synovial cyst. Conclusions Hitherto synovial cysts have not been reported anterior to the dural sac. We describe a lumbar ventral cystic mass with cauda equina compression that mimicked a disc prolapse due to synovial metaplasia. The patient had urgent decompression with subsequent resolution of the symptoms.

Glossopharyngeal neuralgia is a rare disorder. In this article, the condition is defined and its clinical features and diagnostic criteria are described. Treatment of this condition has changed over the years, and evolution of surgical treatment is reviewed. Microvascular decompression for glossopharyngeal neuralgia is described in detail, emphasizing special preoperative anesthetic considerations and up-to-date results and complications.

OBJECTIVE AND IMPORTANCE: Familial colloid cysts of the third ventricle are very rare. This is the largest family reported and the first in which all affected members are female and all members have been screened. Screening led to the diagnosis of an asymptomatic case of a colloid cyst of the third ventricle, and the management of that lesion is discussed. CLINICAL PRESENTATION: A mother and two daughters who were diagnosed with colloid cysts of the third ventricle, from a family containing four sisters, three brothers, and the father, are presented. INTERVENTION: The index patient (Patient 2) underwent computed tomographic scanning-guided stereotactic transcallosal excision of her colloid cyst. Her siblings and her father were screened using magnetic resonance imaging as well as computed tomographic scanning. Cytogenetic analysis of blood samples obtained from the patient and her family revealed no chromosomal abnormalities. CONCLUSION: Screening is of value for families in which two or more members are affected. The management of asymptomatic cases is influenced by the lesion size and the age and fitness of the patient.

The effectiveness of several anatomical and radiological landmarks proposed to determine whether an aneurysm is located intradurally or extradurally is still debated. In anatomical and radiological studies, we examined the relationships of the distal dural ring (DDR) to the internal carotid artery (ICA) and surrounding bony structures to aid in the localization of aneurysms near the DDR. Anatomical relationships were examined by performing dissections on 10 specimens (5 formalin-fixed cadaveric heads). After the position of the DDR, optic nerve, and tuberculum sellae were marked with surgical steel wire, radiographs were taken in multiple projections. The only bony landmark consistently visible on radiographs was the planum sphenoidale. The superior border of the DDR is located at or below the level of the tuberculum sellae, which laterally becomes the superomedial aspect of the optic strut; thus, the optic strut marks the dorsal limit of the DDR. On 50 dry skulls, we measured the vertical distance between the planum sphenoidale and medial aspect of the optic strut (5.0 +/- 0.4 mm), the interoptic strut distance (14.4 +/- 1.4 mm), and the linear distance between the most posterior aspect of the planum sphenoidale (limbus sphenoidale) and the tuberculum sellae (6.0 +/- 0.5 mm). Using these measurements and the planum sphenoidale, tuberculum sellae, and optic strut as reference landmarks, we determined the location of the aneurysm relative to the DDR on angiographic images. In this way, we were able to identify whether lesions were intra- or extradural.

A 63-year-old man with hypertrophic pachymeningitis (HP) and an undifferentiated connective tissue disease is described. Combined therapy with prednisolone and azathioprine improved his symptoms. The association between an undifferentiated connective tissue disease and HP is discussed.

OBJECTIVE: This study was undertaken to assess the reliability of the aspect ratio (AR) (i.e., aneurysm depth to aneurysm neck) in predicting aneurysm rupture. It has been shown that the AR is a key factor in predicting intraaneurysmal blood flow and aneurysm rupture. METHODS: Seventy-five patients with subarachnoid hemorrhage and multiple aneurysms were studied. The sizes of the aneurysms and their ARs were determined by examining the angiographic, films. By comparing the difference between ruptured and unruptured aneurysms in the same individual, each patient in effect served as his or her own control. Each ruptured aneurysm was confirmed during surgery. RESULTS: There were 75 ruptured and 107 unruptured aneurysms. The mean AR was 2.70 for ruptured aneurysms, compared with 1.8 for unruptured aneurysms. This difference between the ARs was statistically significant (P < 0.001). The difference in aneurysm sizes in the two groups also was significant (P < 0.001). CONCLUSION: AR on its own is as reliable a variable as the size of the aneurysm for predicting aneurysm rupture.

Object. The aim of this study was to audit the treatment of symptomatic atlantoaxial instability in Down syndrome and to assess factors associated with fusion failure in this group of patients. Methods. The authors reviewed the cases of 12 children with Down syndrome presenting with symptomatic atlantoaxial instability who underwent surgery for internal fixation and fusion. A review of clinical histories, radiological investigations, and details of operative interventions was also performed. The mode of presentation was acute spinal cord injury (five cases), progressive myelopathy (four cases), and neck pain or stiffness (three cases). The atlantodental interval ranged from 5 to 13 mm. The posterior atlantodental interval at the C-1 level was 9.5 mm (range 6-11 mm). In 10 patients an os odontoideum was present. Translocation of the odontoid process occurred in one patient, and occipitoatlantal instability was also identified in two cases. Twenty-four operations were performed in the 12 patients. A transoral odontoidectomy was required in four children. Successful fusion was demonstrated in seven patients at the first operation. Three of the five patients with acute cord injury made significant functional recovery and were left with no or mild disability. Conclusions. Additional bone abnormalities at the CVJ are common in the Down syndrome population. Young age at the time of fusion and multiple osseous anomalies pose a higher risk factor in fusion failure. The authors recommend an aggressive surgical approach for management of symptomatic cases of CVJ instability