No abstract

With further investigation, these findings could help guide clinical rehabilitation of patients with torn meniscus tissue, especially in the context of the patients' increased risk of joint degeneration.

The development of a progressive neurological deficit extending to segments beyond the site of cord injury, months or years after the original trauma and shown subsequently to be due to the development of a syrinx cavity within the cord, is a rare but well documented occurrence. 1-3 6-9 Barnett7 found clinical features suggesting syrinx formation in 1-8% of a series of 319 posttraumatic paraplegic patients. On the basis of the similarity of clinical manifestations to those seen in syringomyelia, he concluded that the lesion was a cystic degeneration of the spinal cord, although such a cyst was confirmed in only two of his eight cases, in one at operation and in another at necropsy. Our recent experiences suggest that some of the features of post-traumatic syringomyelia are amenable to surgical intervention and the purpose of this paper is to call attention to this relatively rare complication of spinal cord trauma, and the possibility of partial relief.

SUMMARY The investigation and surgical closure of a subarachnoid pleural fistula following direct trauma to the dorsal spinal theca and spinal cord are described and a review of the literature on spinal subarachnoid-pleural fistula is presented.Direct or indirect trauma to the chest wall and dorsal spinal column may result rarely in a fistulous connection between the pleural space and the subarachnoid space. The detection and localisation of this kind of fistula is challenging. In this paper a case of subarachnoid-pleural fistula is described and by reference to the previously reported eleven cases attention is drawn to several problems peculiar to the management of this clinical entity. Case reportA 27-year-old male Indonesian sustained several stab wounds in the chest, resulting in his emergency admission to a surgical thoracic unit where the knife was found to be still in situ; no additional injuries were noted.At thoracotomy the knife was removed and about 11 litres of clotted blood evacuated from the pleural cavity. It then proved very difficult to control bleeding which was coming from the spine so that a laminectomy and costo-trasversectomy were performed and revealed a tear in the dura and pia arachnoid. The bleeding was controlled and the dura closed. Although the patient made an otherwise uneventful recovery he developed signs of a complete cord lesion at the D4 level.In the course of investigation for pyrexia, in a rehabilitation unit, a large left pleural effusion was noted, with no evidence of pneumothorax. Repeated aspiration as well as a short period of pleural drainage failed to clear the blood stained sterile fluid. Detailed biochemical analysis of the aspirate, including electrophoresis, failed to establish the presence of CSF in the transudate. The patient was transferred to a neurosurgical unit with a tentative diagnosis of subarachnoid pleural fistula.Plain radiographs of the spine and chest revealed bony defects due to the surgery and a left sided pleural effusion. Metrizamide myelography showed atrophy of the upper dorsal spinal cord and irregularity of the theca at D4 level (fig a, b). There was no obstruction and, despite elective positioning, no leakage of contrast medium from the theca could be recognised. A CT scan, performed about 3 hours after the myelogram confirmed the cord atrophy. The pleural fluid at this time was of relatively high density (50 HU), which finding is compatible with contamination by a small amount of metrizamide, but could also be caused by blood and protein in the effusion. A myelogram was performed using Tc99 which revealed immediate extension of radioactivity laterally from the left side of the theca at D4 level followed by high radioactivity in the left pleural cavity (fig c, d). TreatmentThe theca was widely exposed at the previous level of trauma using an anterolateral approach and on entering the pleural cavity there was an efflux of serosanguineous fluid. After opening the dura, sharp and blunt dissection revealed a fistulous opening in the dura mater an...