The management of traumatic cervical bilateral facet fracture-dislocations with unicortical anterior plates.

The goal of this study was to evaluate single-level anterior cervical discectomy and stabilization for bilateral facet fracture dislocations using bone graft and anterior titanium plates with unicortical screw fixation in the clinical setting. We conducted a retrospective review during a consecutive 6-year period of patients treated in a single institution for traumatic single-level cervical bilateral facet fracture-dislocation. All fracture-dislocations that could be aligned with traction were subsequently stabilized using an anterior cervical discectomy with bone graft and titanium unicortical locking plates. All patients were examined after operation for radiographic evidence of healing and neurologic outcome. Twenty-two patients (M:F ratio, 16:6; average age, 47.7 years) underwent an anterior cervical discectomy and stabilization with either an allograft (n = 12) or an autograft (n = 10) and a titanium unicortical locking plate. Most patients had sustained a spinal cord injury (87%) or a radicular injury (9%). The average follow-up was 32 months, with a minimum follow-up of 1 year (range, 13 to 77 months). There was one instrumentation-related failure, but all 22 patients ultimately had evidence of stability at the instrumented level on the final follow-up examination. Anterior fixation with unicortical cervical locking plates as a single procedure offers an excellent surgical alternative in the management of many cervical bilateral facet fracture dislocations in patients who can be reduced preoperatively.

Prevalence of cerebral aneurysms in patients with persistent primitive trigeminal artery.

OBJECT: The aim of this study was to determine the prevalence of cerebral saccular aneurysms in patients with persistent primitive trigeminal artery (PPTA). The prevalence of cerebral saccular aneurysms in patients with PPTA previously has been reported to be 14 to 32%, but this rate range is unreliable because it is based on collections of published case reports rather than a series of patients chosen in an unbiased manner. METHODS: The authors retrospectively evaluated their own series of 34 patients with PPTA to determine the prevalence of cerebral aneurysms in this population. The prevalence of intracranial aneurysms in patients with PPTA was approximately 3% (95% confidence interval 0-9%). CONCLUSIONS: The prevalence of intracranial aneurysms in patients with PPTA is no greater than the prevalence of intracranial aneurysms in the general population.

Surgery for cervical myelopathy in geriatric patients.

OBJECTIVE: The number of geriatric patients seeking surgical treatment for cervical myelopathy is steadily increasing. Although anecdotal experiences have been good, insufficient data exists in the spine literature concerning this particular group. We decided to review our experience to determine efficacy of surgical management and examine our morbidity with this select group. METHODS: We undertook a retrospective review of all surgical procedures for nontraumatic cervical myelopathy performed at Mt Sinai Medical Center and Jackson Memorial Medical Center between January 1 1987 and June 1 1992, in patients older than 70 years of age (33 men and 18 women). RESULTS: A total of 53 cervical surgical procedures were performed in 51 patients (nine expansile laminoplasties, 20 anterior cervical diskectomies and fusion and 24 decompressive posterior laminectomies). The average hospital stay was 7.7 +/- 3.4 days. Twenty-one (41%) patients required inpatient rehabilitation; the remaining 30 patients received outpatient rehabilitative therapy. The major morbidity rate was 3.9%, and the minor morbidity rate was 5.8%. Perioperative medical complications included cardiac arrhythmias, hypertensive episodes, atelectasis, confusion, urinary dysfunction and hyponatremia. All of these complications resolved except in one patient. The perioperative mortality rate was 2%. Office follow-up was performed for a mean of 11.1 +/- 2.5 months postoperatively. Comparison of preoperative and postoperative functional status was performed using Nurick's criteria as described in the literature. At follow-up, 60.8% of the patients had improvement in their myelopathic symptoms, especially in regard to gait; 33.3% were stabilized and 5.9% had worsened neurological function. CONCLUSION: This study demonstrates that corrective surgical procedures for significant nontraumatic cervical myelopathy in the geriatric population may be performed safely, that is, with acceptable risk of morbidity and reasonable expectation for clinical improvement.

Pediatric oligodendrogliomas.

Pediatric oligodendrogliomas are infrequently occurring brain tumors and frequently thought of as benign. The literature examining treatment and outcome in this select population is sparse. A retrospective analysis of pediatric oligodendrogliomas treated at MD Anderson Cancer Center between 1973 and 1992 was performed. Oligodendrogliomas were histologically graded according to the method of Smith. Survival data were estimated with Kaplan-Meier curves. Mean follow-up was 39.7 months. Nineteen children had histologically verified oligodendrogliomas and mixed oligodendroglioma/astrocytoma (M:F = 11:8; age range 1-18 years, mean = 13.1). Presenting symptoms included seizures (n = 10), headache (n = 3), visual field defects (n = 2), weakness (n = 2), cranial nerve palsy (n = 1) and decreased school performance (n = 1). All patients underwent craniotomy: 13 subtotal resections, 5 gross total resections and 1 biopsy. Twelve children had adjuvant therapy including radiation (n = 12), chemotherapy (n = 5) or both (n = 5). The 5-year survival was 65%. Seizure frequency was reduced in 30%. Children with oligodendrogliomas do not have a benign course, but younger children (<12 years) have a better prognosis. Histologic classification correlates with survival. Completeness of resection was not found to be a factor relating to survival. No conclusions can be drawn concerning adjuvant therapy because of selection bias.

Intramedullary holocord lipoma in an athlete: case report.

OBJECTIVE AND IMPORTANCE: Holocord intradural lipoma extending from the cervical to the lumbar spine is an exceedingly rare condition. An extensive review of the literature revealed that only eight other cases have been reported, and none occurred during the contemporary magnetic resonance imaging era. CLINICAL PRESENTATION: A case of holocord intradural lipoma that was partially resected with the aid of carbon dioxide laser and intraoperative ultrasound is reported. TECHNIQUE: The intimate relationship of the lipoma to the nerve roots and the absence of a distinct plane between tumor and spinal cord precluded a complete resection of this tumor. At 7 months postoperatively, the patient's dysesthetic pain had resolved almost completely. Proprioception in the lower extremities had improved significantly to the point that the patient was able to walk without a cane and his preoperative Romberg's sign had disappeared. CONCLUSION: Extensive intradural intramedullary spinal lipomas can present in adulthood with symptoms of myelopathy as well as nonradicular pain. We encourage early surgical debulking of the tumor to prevent further progression of symptoms and to offer the possibility of neurological improvement.

Bilateral craniotomies for blunt head trauma.

Development of delayed or recurrent intracranial hematomas requiring reexploration or a secondary craniotomy is well known. Patients with bilateral pathology requiring bilateral craniotomies as the initial emergency operative intervention, however, are uncommon. The lack of available literature and the large volume of head trauma seen at our institution prompted us to analyze the retrospective data on blunt head injury requiring bilateral craniotomies. Twenty patients underwent bilateral craniotomies at the University of Miami/Jackson Memorial Medical Center between January 1986 and June 1994. Ages ranged from 18 to 85 years. Mechanism of injury included motor vehicle crash (n = 4), pedestrian hit by automobile (n = 4), assault (n = 8), fall from height (n = 3), and unknown (n = 1). Epidural hematomas, acute subdural hematomas, contusions, and intracerebral hematomas were seen in varying combinations. The preoperative Glasgow Coma Scale (GCS) score ranged from 4 to 14, with a mean of 8.8 (+/-0.82 SE). Sixteen of the 20 patients survived and were discharged from the hospital. The survivors' Rancho Los Amigos Scale score on discharge ranged from 2 to 8, with a mean of 6.1 (+/-0.45 SE). A Fisher's exact test was performed to compare the outcome between the patients with mild (GCS score 13-15) to moderate (GCS score 9-12) head injury and those with severe (GCS score 4-8) head injury. It showed a statistically higher frequency of death in the severe category (p < 0.05). In conclusion, the outcome of patients with bilateral pathology requiring emergency bilateral craniotomy at initial treatment correlated well with their GCS scores at initial presentation.

Split notochord syndrome: case report.

Split notochord syndrome includes a cleft of the vertebral column associated with malformation of the central nervous system. Fourteen cases involving the lumbosacral spine have been reported in the literature. We report on a female neonate who had intact function of her lower extremities, a posterior midline lumbar defect bounded by two complete spinal canals that contained two spinal cords. A meningocele, a large bowel fistula, and a mature teratoma protruded through the cleft. The baby is doing well after repair of the anomaly and placement of a ventriculoperitoneal shunt.

Time course of ciliary neurotrophic factor mRNA expression is coincident with the presence of protoplasmic astrocytes in traumatized rat striatum.

Adrenal grafting for Parkinson's disease has led to modest functional improvement despite poor graft survival. One explanation is a neurotrophic response within the traumatized striatum. This study was undertaken to investigate the time course of the astrocytic response in vivo and in vitro, and the expression of ciliary neurotrophic factor (CNTF) mRNA following striatal injury. Unilateral stereotaxic biopsy of the rat striatum was performed and gelatin sponge (gel-foam) was immediately placed into the biopsy cavity. Rats were sacrificed on days 1, 3, 5, 7, 14, and 28 post biopsy. Immunohistochemical staining of the traumatized striatum with antibodies to glial fibrillary acidic protein (GFAP) was carried out. The reactive astrocytes which appeared within 7 days after trauma were mostly protoplasmic on the basis of morphology, and maximal on day 7, being 30 times the level in the normal striatum. After day 7, fibrous astrocytes appeared and increased up to day 28, while protoplasmic astrocytes decreased. In addition, immunocytochemical double staining of short term cultured astrocytes from the traumatized striatum with anti-A2B5 and anti-GFAP antibodies revealed that 84% and 90% of astrocytes were type 1 astrocytes on days 3 and 7, respectively; however, by day 28 47% of astrocytes were type 2. Northern blot analysis revealed that CNTF mRNA expression was up-regulated and peaked on day 7, coincident with a predominance of protoplasmic astrocytes in vivo and type 1 astrocytes in vitro, respectively. These findings suggest that the expression of CNTF mRNA is part of the early astrocytic response to trauma, particularly associated with protoplasmic astrocytes in vivo and type 1 astrocytes in vitro.(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebrovascular histopathology after intracarotid infusion of Gelfoam in the rat.

To evaluate the histopathology of Gelfoam on the cerebral vasculature, 42 Sprague-Dawley rats weighing 250 to 300 g received internal carotid artery infusions of 0.3 ml of Gelfoam solution (5 mg/ml) or normal saline (0.9%). The animals were killed at 1 hour, 5 hours, 3 days, 1 week, 2 weeks, and 4 weeks after the infusion. The brains were removed, sectioned, and stained with hematoxylin and eosin. Examination of brain sections revealed Gelfoam emboli lodged primarily in the small leptomeningeal arteries. At 5 hours after infusion, inflammatory cells were noted in the arterial walls with vessel occlusion. Further canalization of vessels was noted at 1 week. At 4 weeks, Gelfoam was not seen in the specimens. This study suggests that Gelfoam acts as an embolic agent in vessels over short periods of time with no residual inflammatory activity postinfusion.

Bilateral infrapopliteal artery aneurysms.

The authors report the case of a 37-year-old man with bilateral posterior tibial artery aneurysms and concomitant collagen vascular disease. The patient initially presented with pain and swelling of the calves. The diagnosis was made by duplex scan and confirmed with arteriography. Diagnostic studies later verified the presence of a lupus-like syndrome. To date, 10 patients with aneurysms of the infrapopliteal arteries have been reported in the literature; four of these have had associated systemic diseases. These reports are reviewed; their clinical manifestations are discussed, and a treatment plan for these uncommon lesions is presented.

Neurological injury and patterns of sacral fractures.

To evaluate the morphological and neurological findings in sacral spine injuries, a retrospective study was conducted of all patients admitted to Erie County Medical Center over a 2-year period with the diagnosis of pelvic or sacral injury. Of these 253 patients, 44 were found to have sacral fractures and form the basis of this study. The type of fracture, neurological deficit, treatment, and outcome in these patients were analyzed. The patient population consisted of 25 males and 19 females, with a mean age of 34 years (range 15 to 80 years). The fractures were classified by the degree of involvement of the foramina and central canal. Fractures through the ala sacralis only (Zone I, 25 cases) or involving the foramina but not the central canal (Zone II, seven cases) were less likely to cause nerve injury (24% and 29%, respectively). Fractures involving the central canal (Zone III), both vertical (five cases) and transverse (seven cases), were more likely to cause neurological injury (60% and 57%, respectively). Neurological deficits in Zone I and II injuries were usually unilateral lumbar and sacral radiculopathies. Zone III deficits were usually bilateral and severe; bowel and/or bladder incontinence was present in six of the 12 patients in this group. Deficits generally improved with time; however, operative reduction and internal fixation may have been useful, particularly in patients with unilateral root symptoms. The treatment options are discussed, and previously published series of sacral fractures are reviewed. The authors conclude that the classification of sacral fractures described is useful in predicting the incidence and severity of neurological deficit.