Reduction of head size in advanced hydrocephalus: a case report.

On October 8, 1951, at the dawn of modern neurosurgical treatment of hydrocephalus and other cranial abnormalities, the parents of a child with advanced hydrocephalus posed the question: might the size of the head be reduced so as to allow sitting, standing, and perhaps walking? With the ingenious assistance of the child's father, who devised and made unique surgical instruments, the objectives were accomplished over a period of almost 2 years during which more than a dozen operations were carried out, including one of the first lumbar subarachnoid to peritoneum shunts using the Touhy needle instead of laminectomy. The operations conducted, the devices and tactics used, and the end results are described. No opportunity to treat another patient similarly has presented itself in the over 30-year interval since then, but I believe that the concept is valid and that success is realizable by others who may wish to use some of the techniques described, with appropriate modification.

Interhemispheric and percallosal (transcallosal) approach to the cingulate gyri, intraventricular shunt tubes, and certain deeply placed brain lesions.

The author reports 52 interhemispheric and percallosal operations carried out by himself and certain of his associated trainees upon 50 patients presenting 19 different pathological entities over a period of 38 years (1944 through 1982). The still too little appreciated advantages of this approach over transcortical avenues to the anterior ventricular system are described, together with specific indications, contraindications, and reliable and proven surgical techniques. The long term results are examined for four different outcomes: (a) recovery without deficit or with a deficit wholly chargeable to the lesion before its extirpation; (b) recovery, but with a deficit produced by or increased by the surgical procedure; (c) failure to benefit; and (d) death due to the operation. Eleven patients had invasive tumors that were not totally removable, and 6 died postoperatively. Five survived with disease-produced deficits that failed to disappear. Two had permanent deficits due to intraoperative misfortunes. Twenty-six made full recoveries, with return to work or school. Only 1 patient had a postoperative seizure problem.

Cervical spondylotic radiculopathy producing motor manifestations mimicking primary muscular atrophy.

Cervical radiculopathy unaccompanied by pain or sensory disorder but manifested only by paresis, atrophy, fasciculation, and reflex loss is unusual. Three such cases are presented. Considerable diagnostic difficulty may arise in distinguishing patients presenting with these features from those who have primary motor neuron disease. Two additional case reports demonstrate that this distinction is not always possible. Diagnosis, management, and prognosis are discussed. Differentiation between motor neuron disease and spondylosis will avert needless surgery in the former group and will result in beneficial, sometimes curative surgery in the latter group.

Occipital neuralgia and the C1-2 arthrosis syndrome.

Occipital neuralgia syndromes have been ascribed to a great many pathological alterations, some demonstrable and some hypothetical. Recently, occipital neuralgia has been attributed to developmental and posttraumatic lesions in the cervicocranial junction region, with the nerve roots at C-1 and C-2 considered to be the principal pain pathways. The authors describe a series of seven patients with an upper neck and occipital pain syndrome due to unilateral degenerative disease (arthrosis) of a C1-2 lateral articulation. Two of the cases are presented in detail. This disease is demonstrable by radiography through the open mouth by isotope bone scanning, and by computerized tomography scanning. Temporary relief may be obtained by anesthetic and steroid injection, and permanent relief achieved by C-2 dorsal rhizotomy.

Posterior lumbar vertebral rim fracture and associated disc protrusion in adolescence.

Two cases of posterior lumbar vertebral rim fracture and associated disc protrusion in adolescents are presented. Disc compliance and developing vertebral structure were thought to be primarily responsible for this unusual injury. Occurring primarily in adolescent males, this entity most commonly affects the L-4 vertebra. One of the cases involved disc rupture at three levels. This injury is thought to be due in part to union of the anuli by the posterior longitudinal ligament, and in part to rim fracture and limited prolapse rather than frank single-level herniation in an adolescent. A review of the embryology, literature, and theoretical mechanism for occurrence at multiple levels is included.

Diagnosis and treatment of abscess of the central ganglia.

The authors present four cases of abscess of the thalamus and basal ganglia and review an additional 10 cases from the literature. These abscesses appear to be metastatic and are usually associated with a cardiac septal defect or a preceding intrathoracic infection. Fever, elevated white blood count, and/or meningismus, in combination with angiography demonstrating an avascular mass, help distinguish abscess from tumor in this location. The authors advocate aspiration rather than excision.

Degenerative lumbar scoliosis.

Recent work on degenerative lumbar curves has focused on stable deformities with entrapment syndrome secondary to spondylotic compression. A review of our local experience with degenerative lumbar curves shows that approximately half of the 14 cases have had a less typical radiographic presentation of short reciprocating lumbar curves thought to be on the basis of asymmetric intervertebral osteochondrosis. In these latter cases, marked spondylotic ridging and intervertebral buttressing were absent; therefore, major decompressive surgery on the residual posterior elements may increase instability and hasten further collapse. Although most patients have had good relief of radicular leg complaints with decompressive procedures, several patients had persistent low-back pain that appeared to have a mechanical basis. In those instances of potentially increased postoperative instability or persistent mechanical back complaints, consideration should be given to augmenting decompressive procedures with Harrington instrumentation and fusion for these painful collapsing lumbar spines.

Spinal arachnoiditis. The postoperative variety in particular.

The diagnostic and therapeutic courses of 68 patients with the discharge diagnosis of spinal arachnoiditis were reviewed. The combination of oil myelography and spinal surgery was the probable cause of arachnoiditis in almost all cases. The clinical presentation featured leg pain (90%), low-back pain (80%), and sphincter disturbance (25%). Motor, sensory, and reflex changes were present in two thirds of the cases, with a majority having defects attributable to bilateral or multiple root level involvement. Specific analysis of previous operative procedures cerebrospinal fluid (CSF) studies, and myelographic patterns did not disclose any consistent correlation with the clinical presentation. Results are interpreted in light of prior clinical and experimental studies on the reaction of the meninges to trauma and myelography.

Torkildsen's ventriculocisternostomy: some complications and their prevention.

Torkildsen's ventriculocisternostomy retains a certain usefulness despite the recent popularity of newer procedures. Despite many modifications and suggestions for improving the procedure, certain hazards and complications remain. We report instances of myelopathy from contact with and impalement by the cervical end of the tube, acute quadriplegia, unsuspected kinking of the catheter and late ventricular catheter malposition together with certain suggestions for modifications of technique which we believe will make Torkildsen's shunting more reliable and safe.

Nasopharyngeal carcinoma metastatic to the cauda equina.

A case of nasopharyngeal carcinoma metastatic to the cauda equina is reported. The patient, treated 3 years earlier for his primary disease, presented with bilateral weakness of his legs. Myelographic studies showed only patchy thickening of certain lumbosacral nerve roots. A biopsy from a root in the cauda equina was made through a T-12 to L-2 laminectomy revealing carcinomatous involvement. Careful examination of the specimen was necessary to distinguish the tumor from a lymphoma. Review of the literature has revealed no other cases of this type of neoplastic metastasis.