Subdural haematomas in the elderly: experience with treatment by trephine craniotomy and not closing the dura or replacing the bone plate.

A surgical technique was devised to treat chronic subdural haematomas (SDH) in elderly patients. Initial good results encouraged the author to use this technique in elderly patients with acute SDH. This small group is also reported. The goal was to do definitive, not expectant or incremental surgery on these fragile patients who have a high incidence of co-morbid conditions and cerebral atrophy, and to obliterate the subdural space by allowing the skin to sink into the cranial defect. The surgical technique consists of trephine craniotomy and not closing the dura or replacing the bone plate. Experience with six elderly patients with acute SDH and 23 patients with chronic SDH is reported. Of six patients with acute SDH, mean age 80 years, 2 months, three died, all with a Glasgow Coma Score (GCS) less than 9. Three recovered to preoperative status, one with initial GCS of 7 and the other of 8. Of 23 patients with chronic SDH, mean age 77 years, 21 recovered to preoperative status. The two deaths were in patients with GSC of 5 and 7. There were no recurrent SDH or postoperative surgical or cosmetic complications. All patients were followed for at least 6 months. These excellent results suggest that the procedure could be considered as a first procedure in the elderly patient. At first glance, the operation appears to be overly aggressive, but it is an example of 'aggressive-conservative' treatment which produces good long-term results with few complications and no need for second operations.

Surgery for patients with central protruded lumbar discs who have failed conservative therapy.

The clinical presentation and results of surgery of patients with central protruded lumbar discs have not been well defined or distinguished from studies of patients with lateral herniated discs. Many patients are denied surgical treatment, even though they are incapacitated by pain, because they do not have the classic radiographic findings seen in patients with lateral disc herniation. Sixty-three symptomatic patients with radiographically documented central lumbar disc protrusion were analysed. All patients had failed at least 6 months of conservative therapy. Although lumbar spinal pain was the most common complaint, 24 patients also presented with bilateral leg pain and 33 with unilateral leg pain; 26 had unilateral limitation of straight leg raising. An interesting observation was that unilateral symptoms and dural tension signs can be seen in patients with central disc protrusion. After surgical follow-up for a mean of 51 months, 86% achieved good results when analysed by the Prolo Functional Economic Outcome Rating Scale. It is postulated that pain is mediated by neuropeptides and arachidonic acid degradation products which are a response to mechanical annular injury.

The use of clip-suture in thoracic sympathectomy. Technical note.

A technique is described for using a clip-suture to expedite handling of the divided sympathetic chain in a deep, small upper-thoracic exposure. No late failures were experienced in 23 patients with hyperhydrosis surgically treated using this technique.

The piriformis muscle syndrome: a simple diagnostic maneuver.

Current maneuvers to diagnose the piriformis syndrome are less than ideal. Freiberg's maneuver of forceful internal rotation of the extended thigh elicits buttock pain by stretching the piriformis muscle, and Pace's maneuver elicits pain by having the patient abduct the legs in the seated position, which causes a contraction of the piriformis muscle. This report describes a maneuver performed by the patient lying with the painful side up, the painful leg flexed, and the knee resting on the table. Buttock pain is produced when the patient lifts and holds the knee several inches off the table. The maneuver produced deep buttock pain in three patients with piriformis syndrome. In 100 consecutive patients with surgically documented herniated lumbar discs, the maneuver often produced lumbar and leg pain but not deep buttock pain. In 27 patients with primary hip abnormalities, pain was often produced in the trochanteric area but not in the buttock. The maneuver described in this report was helpful in diagnosing the piriformis syndrome. It relies on contraction of the muscle, rather than stretching, which the author believes better reproduces the actual syndrome.

Sciatica and epidural gas.

Epidural gas in the patient with sciatica can sometimes provide a clue that there is a surgically treatable lesion. Our patient had the sudden onset of sciatica at night, which was relieved by walking. An intraspinal synovial cyst was associated with epidural gas.

Splitting of the optic nerve by a carotid-ophthalmic artery aneurysm. Case report.

A patient with splitting of the optic nerve by a carotid-ophthalmic artery aneurysm is presented. Possible explanations for this previously unreported configuration are discussed.

Myxomatous degeneration of the lumbar intervertebral disc.

Sixteen patients were operated on for lumbar pain and pain radiating into the sciatic nerve distribution. In all 16, when the anulus fibrosus was incised, soft, gray disc material extruded under pressure like toothpaste being squeezed from a tube. This syndrome of myxomatous degeneration is a distinct entity, different from classical fibrotic disc degeneration or herniated nucleus pulposus. Surgical removal associated with partial facetectomy produced excellent results. The concept of incompetence of the anulus fibrosis is discussed.

Vocal cord paralysis associated with anterior cervical fusion: considerations for prevention and treatment.

In a series of 375 patients with anterior cervical fusions, long-term follow-up results complete with laryngeal examination were obtained in 102 patients. One patient was found to have an inferior laryngeal nerve palsy, and one had a superior laryngeal nerve palsy. Both deficits were thought to be the result of surgical trauma. Measures to minimize the incidence of vocal cord paralysis include careful surgical technique and knowledge of the surgical anatomy of the laryngeal nerves. Suggestions are given for the assessment of postoperative hoarseness, and for the management of vocal cord paralysis.

Problems in estimating non-disjunction rate from the F-bodies of two-headed human spermatozoa.

The F-bodies of two-headed human spermatozoa offer a unique potential for estimating non-disjunction rate of the Y chromosome. But there is an unexplained quantitative discrepancy: a gross deficiency of two-headed spermatozoa with no F-bodies, relative to the numbers with one F-body in each head. Any estimation of non-disjunction rate would be overshadowed by this and other major factors. Two-headed spermatozoa cannot be regarded as a random aggregation of haploid heads in pairs. DNA measurements confirmed that each head of 25 normal-sized two-headed spermatozoa was haploid. The distribution of F-body classes is independent of whether sperm tails are single or double. Donors with an exceptionally high incidence of two-headed spermatozoa exist.

Dissecting hematoma of the internal carotid artery following chiropractic cervical manipulation.

A patient with a dissecting hematoma of the internal carotid artery following chiropractic neck manipulation is described. This injury, apparently previously unreported in the literature, is thought to be caused by trauma to the artery by rotatory movement of the neck and pressure against the artery by the transverse process of C-2.

F-bodies as Y chromosome markers in mature human sperm heads: a quantitative approach.

It is generally accepted that at least some Y chromosomes in human mature sperm heads are represented in preparations by fluorescent F-bodies. From data consisting solely of F-body scorings and the visually estimated size of sperm heads from normal donors, a quantitative model is developed which permits simultaneous estimation of six parameters representing biological factors (the proportions of ploidy classes and of their sex-chromosome complements) and biassing factors (not all Y chromosomes represented by F-bodies, not all F-bodies representing Y chromosomes, and error in scoring ploidy from visual size). The analysis is statistically adequate and succeeds in predicting a variety of independently validated phenomena. The work may be regarded as a contribution to the integration of qualitative and quantitative evidence in the study of F-bodies. In all, 21,700 one-headed spermatozoa from 12 donors were scored. A mean of 54% spermatozoa lacking F-bodies was subject to a standard deviation between donors of 4.8, over and above binomial error. Analysis yielded the following estimates: 83.3% of diploid spermatozoa are XY, the remainder XX and YY in assumed equal number (this information assists analysis of the origin of embryonic triploidy); 2.4% of spermatozoa are diploid (this estimate does not compete in accuracy with direct estimates from DNA absorbance); only 83% of Y chromosomes are represented by F-bodies; 7% of haploid heads and 14% of diploids contain one or more "adventitious bodies" indistinguishable from true F-bodies. The visually scored head sizes "Small" and "Medium" correspond approximately with haploidy and diploidy; nearly all haploids are scored as Small, and 72% of the Medium are diploid. F-bodies are not thought at present to give a useful basis for estimating the presumably low incidence of sex-chromosome aneuploidy and nondisjunction. No such estimate has been attempted. The problem is overshadowed by not fully understood complicating factors of greater magnitude, which now appear to be a major subject of enquiry. Some implications and possible future developments are discussed.