Spinal epidural abscess (SEA) was first described in the medical literature in 1761 and represents a severe, generally pyogenic infection of the epidural space requiring emergent neurosurgical intervention to avoid permanent neurologic deficits. Spinal epidural abscess comprises 0.2 to 2 cases per 10,000 hospital admissions. This review intends to offer detailed evaluation and a comprehensive meta-analysis of the international literature on SEA between 1954 and 1997, especially of patients who developed it following anesthetic procedures in the spinal canal. In this period, 915 cases of SEA were published. This review is the most comprehensive literature analysis on SEA to date. Most cases of SEA occur in patients aged 30 to 60 years, but the youngest patient was only 10 days old and the oldest was 87. The ratio of men to women was 1:0.56. The most common risk factor was diabetes mellitus, followed by trauma, intravenous drug abuse, and alcoholism. Epidural anesthesia or analgesia had been performed in 5.5% of the patients with SEA. Skin abscesses and furuncles were the most common source of infection. Of the patients, 71% had back pain as the initial symptom and 66% had fever. The second stage of radicular irritation is followed by the third stage, with beginning neurological deficit including muscle weakness and sphincter incontinence as well as sensory deficits. Paralysis (the fourth stage) affected only 34% of the patients. The average leukocyte count was 15,700/microl (range 1,500-42,000/microl), and the average erythrocyte sedimentation rate was 77 mm in the first hour (range 2-50 mm). Spinal epidural abscess is primarily a bacterial infection, and the gram-positive Staphylococcus aureus is its most common causative agent. This is true also for patients who develop SEA following spinal anesthetics. Magnetic resonance imaging (MRI) displays the greatest diagnostic accuracy and is the method of first choice in the diagnostic process. Myelography, commonly used previously to diagnose SEA, is no longer recommended. Lumbar puncture to determine cerebrospinal fluid protein concentrations is not needed for diagnosis and entails the risk of spreading bacteria into the subarachnoid space with consequent meningitis; therefore, it should not be performed. The therapeutic method of choice is laminectomy combined with antibiotics. Conservative treatment alone is justifiable only for specific indications. Laminotomy is a therapeutic alternative for children. The mortality of SEA dropped from 34% in the period of 1954-1960 to 15% in 1991-1997. At the beginning of the twentieth century, almost all patients with SEA died. Parallel to improvements in the mortality rate, today more patients experience complete recovery from SEA. The prognosis of patients who develop SEA following epidural anesthesia or analgesia is not better than that of patients with noniatrogenic SEA, and the mortality rate is also comparable. The essential problem of SEA lies in the necessity of early diagnosis, because only timely treatment is able to av...

Six endoscopic fenestrations of the 3rd ventricular floor have been performed in patients with stenosis (SAS) of the aqueduct of Sylvius in our institute during the last two years. The endoscopic intraventricular landmarks were the Monro's foramen followed by the mamillary bodies. The fenestration instrument was a monopolar coagulation wire, the dilatation instrument was a balloon catheter. The patients included two newborns and four adults. The two newborns developed a recurrent hydrocephalus after 2 months. The four adults remained well after the operation. The only complication was edema (SIADH syndrome) in one case for 24 hours. Flow sensitised phase MRI showed a mirroring in the prestenotic CSF pulsation curve preoperatively. This, in combination with an increased intraventricular pulsation, is a sign of reduced capacity of the subarachnoid space at the cerebral surface. The postoperative patency of the fenestration with diminished intraventricular pulsation can be demonstrated with ECG retrogated phase MRI. There was a slow and incomplete decrease of the preoperative enlarged ventricular size. This operative method is a low-risk, minimal invasive alternative method to shunt implantation in adults with SAS.

] or lumbosacral extradural [5,12,15,16,25,38,50] arachnoid cysts can take the form of space-occupying cystic dilatations of the lumbosacral nerve roots at or distal to the junction of the posterior root and the dorsal ganglion. Both terms are used for the same entity. They are a rare disease. Although this entity has been known since 1937 [16], there are only a few publications describing the clinical course of more than one or two cases [7,24,36,45,47]. In 1959 Nugent reported on seven surgical cases [31]. Recently, Kendall et al. discussed six of their own cases of operated extradural arachnoid cyst, but only two of them were situated in the lumbosacral region [24]. Palmer studied the frequency of spinal arachnoid cysts at the Department of Neurosurgery at the Radcliffe Infirmary in Oxford (UK) in the years 1938-1970, and found only one extradural lumbar arachnoid cyst [32]. The clinical significance remained doubtful [9,34].The availability of MRI has resulted in an increasing number of patients with incidentally diagnosed extradural arachnoid cysts. A total MRI incidence of 4.6% and 1% with symptoms is reported [34]. The higher number of nearly 10%, cited by Xiao in another myelographic study, includes very common small radicular abnormalities [51]. Patients may suffer from different types of low back pain and sciatica. No critical discussion of the indication for surgery has been found in literature so far. Our aim was to compare the results in patients with operative and conservative treatment to define standards for a good surgical result. On account of the low frequency of this entity a prospective study is impossible. Materials and methodsThe clinical records of all patients with a lumbosacral extradural arachnoid cyst attending the neurosurgical department of our hospital in the years 1987-1995 were surveyed. Over these 9 years we operated on 2995 patients with lumbar space-occupying lesions. In Abstract No critical discussion of the indication for the surgical treatment of lumbosacral extradural arachnoid cysts is found in the literature. Therefore, we want to compare the results in patients with operative and conservative treatment to define standards for a good surgical result. Over a period of 9 years, we operated on eight patients with a lumbosacral extradural arachnoid cyst and treated eight others conservatively. Only three of the operated patients experienced a postoperative relief of pain, but none was symptom free. The only one with continuing success had a preoperative history of 1 year only. MRI scans without contrast agent were misinterpreted in one included and one excluded case. The results of conservative treatment were nearly the same as those of operative treatment. MRI is the best diagnostic tool, but a variety of sequences must be used. Patients with a short pain history and a clear neurological deficit profited most from surgery. Patients with slight and not clearly related uncharacteristic symptoms should be excluded from surgery. Key words

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Diagnosis and therapeutic principles are discussed on the basis of a case study of a 21-year-old soldier with an unusual craniocerebral gunshot wound.