SUMMARY:A 53-year-old woman with superficial siderosis underwent spinal MR imaging, which demonstrated a large cervicothoracic epidural fluid collection compatible with a CSF leak. Conventional and dynamic CT myelography failed to localize the dural tear because of rapid equilibration of myelographic contrast between the thecal sac and the extradural collection. The superior temporal resolution of digital subtraction myelography precisely localized the CSF leak preoperatively and led to the successful surgical correction of the dural tear.O ne limitation of CT myelography to identify a CSF leak is temporal resolution. During the time elapsed from intrathecal contrast injection under fluoroscopy to acquisition of the CT images, equilibration of contrast between intradural and extradural CSF collections occurs. When the extradural CSF collection is large, localizing the responsible dural tear can be challenging as a result. Dynamic CT myelography has been used to overcome this problem 1 but still has temporal limitations inherent to the volume of tissue that must be imaged. We describe the case of a patient in whom chronic bleeding from a thoracic dural tear was the presumptive cause of superficial siderosis. The site of the tear was not adequately defined by myelography, postmyelography CT, or dynamic CT myelography, but digital subtraction myelography provided accurate preoperative localization. Case ReportA 53-year-old woman with progressive impaired balance, hearing loss, lower extremity numbness, and chronic daily headaches for the past 5 years underwent neurologic evaluation at our institution. On physical examination, the salient abnormalities included brisk reflexes in both upper and lower limbs, mute plantar responses, asymmetric impairment to light-touch and pin-prick sensation in both legs below the groin, prominent dysmetria on heel-to-shin testing, a widebased ataxic gait, and positive Romberg test. An audiogram confirmed right-greater-than-left sensorineural hearing loss. Tibial somatosensory-evoked responses revealed a prolonged lumbar-scalp interpeak latency suggesting a central conduction delay. The results of an atraumatic lumbar puncture included 1ϩ xanthochromia, 48 red blood cells per microliter, elevated protein of 122 mg/dL, and hemosiderin-containing macrophages.MR imaging of the brain and entire spine revealed prominent T2 shortening along the surface of the cerebellum, brain stem, and spinal cord consistent with susceptibility from hemosiderin deposition. A nonenhancing ventral epidural spinal fluid collection extended from the inferior aspect of C4 through the T6 -T7 disk space ( Figs 1A, -B). Moreover, a T2 hypointense fluid-fluid level suggestive of blood products was layering dependently in the distal thecal sac (not shown).Results of 3D time-of-flight head MR angiography were unremarkable. Because gadolinium-enhanced MR angiography of the spine suggested mildly prominent and serpiginous vessels along the dorsal aspect of the distal cord, the patient underwent catheter spinal angiogra...

The syndrome of orthostatic (low pressure) headaches is well described and most commonly occurs following deliberate violation of the dura (e.g. lumbar puncture). This syndrome can also occur spontaneously and results from the leakage of CSF. We describe three patients who suffered from spontaneous CSF leaks secondary to bony pathology of the cervical spine, and propose that this may be a more common aetiology than originally thought. Often these patients are difficult to manage medically, and surgery may be necessary for symptomatic relief.

Digital subtraction myelography is a valuable diagnostic tool for the localization of rapid spinal CSF leaks and should be considered in patients who are clinically suspected to have a dural tear that is accompanied by a longitudinally extensive extradural fluid collection on spinal MRI.

Purpose Stereotactic body radiation therapy (SBRT) is being applied more widely for oligometastatic disease. This technique is now being used for non-spine bony metastases in addition to liver, spine, and lung. However, there are few studies examining the toxicity and outcomes of SBRT for non-spine bone metastases. Methods and Materials Between 2008 and 2012, 74 subjects with oligometastatic non-spine bony metastases of varying histologies were treated at the Mayo Clinic with SBRT. A total of 85 non-spine bony sites were treated. Median local control, overall survival, and progression-free survival were described. Acute toxicity (defined as toxicity <90 days) and late toxicity (defined as toxicity ≥90 days) were reported and graded as per standardized Common Toxicity Criteria for Adverse Events 4.0 criteria. Results The median age of patients treated was 60 years. The most common histology was prostate cancer (31%) and most patients had fewer than 3 sites of disease at the time of simulation (64%). Most of the non-spine bony sites lay within the pelvis (65%). Dose and fractionation varied but the most common prescription was 24 Gy/1 fraction. Local recurrence occurred in 7 patients with a median time to failure of 2.8 months. Local control was 91.8% at 1 year. With a median follow-up of 7.6 months, median SBRT specific overall survival and progression-free survival were 9.3 months and 9.7 months, respectively. Eighteen patients developed acute toxicity (mostly grade 1 and 2 fatigue and acute pain flare); 9 patients developed grade 1–2 late toxicities. Two patients developed pathologic fractures but both were asymptomatic. There were no late grade 3 or 4 toxicities. Conclusions Stereotactic body radiation therapy is a feasible and tolerable treatment for non-spine bony metastases. Longer follow-up will be needed to accurately determine late effects.

Up to 30% of golfers develop the yips, an inability to complete a golf stroke, most often affecting short putts, which worsens with anxiety. 1,2 Yips may be organic (task-specific dystonia) or psychological (anxiety or "choking"). 2-4 We previously found abnormal trains of 4 to 8 Hz, rhythmic, co-contracting bursts of EMG activity in arm muscles of three golfers suggesting a movement disorder. This led to the current investigation.Methods. We studied 20 age-and handicap-matched male right-handed golfers, 10 with the yips and 10 without. Handicap is the golfer's average score over par over the past ‫01ف‬ rounds of golf. Surface EMG electrodes were placed bilaterally on the pectoralis major, deltoid, biceps, triceps, wrist flexors, pronator teres, flexor pollicis longis, wrist extensors, abductor pollicis brevis, and abductor digiti minimi. EEG electrodes were in a standard montage. Recordings were made at a sampling rate of 1,000 Hz, bandpass 1 to 200 Hz using the Neuroscan system (Neuroscan Compumedics, El Paso, TX). Investigators were not blinded. Pre-putting conditions at rest and with arm activation maneuvers, including writing, were recorded. Somatosensory evoked potentials (SEP) were performed by median nerve stimulation at 2.2 Hz using an average ear reference.Putting was performed on an indoor, artificial, flat putting green surface that was 12 feet long with a hole 2 feet from one end. Subjects were evaluated standing with arms relaxed with and without holding the putter. They then performed 75 putts: 30 putts of 6 feet, 10 putts of 3 feet, and 35 putts of 8 feet. The number of putts made and distance from the hole were recorded for each putt. An electronic photocell recorded the initiation of each stroke and the point of impact.EEG-EMG polygraphy was assessed for abnormal activation of muscles including oscillating discharges, co-contractions, and high-amplitude short duration discharges. The N30 amplitude was measured from the averaged SEP at Fz and Cz. Rectification of EMG activity for all leads was performed 6 seconds before the