Reversibility of white matter changes and dementia after treatment of dural fistulas.

We describe two patients with dural fistulas who presented with dementia and diffuse white matter signal changes on MR that significantly improved after surgery. One patient had preoperative embolization.

Posterior cervical laminoforaminotomy for radiculopathy: review of 172 cases.

Laminoforaminotomy performed with the patient in the sitting position with our improved techniques represents an effective treatment for cervical radiculopathy. We present the results of laminoforaminotomies performed in 172 patients with cervical radiculopathy during a 7-year period. The posterior approach in the surgical management of cervical radiculopathy is not only acceptable, but in certain cases is preferable to the anterior approach. When the abnormality is central, broad based and anterior, posterior procedures are unlikely to achieve decompression. However, with lateral or foraminal nerve root compression, the simpler posterior keyhole laminoforaminotomy works well. In our opinion, physicians advocating either procedure exclusively are not providing the patient with the optimal level of care. Our purpose is to present in detail our surgical technique in conjunction with an analysis of our long-term results in clinical situations in which our technique is clearly indicated.

Complications of cervical discography: analysis of 4400 diagnostic disc injections.

Despite extensive experience with diagnostic cervical disc injection, the role of this procedure in the evaluation of patients with degenerative disc disease and severe neck pain remains controversial. Beyond the debate regarding its efficacy in identifying the site of cervical symptomatology and directing appropriate intervention are the potential morbidity and mortality associated with this diagnostic procedure. Discitis, subdural empyema, spinal cord injury, vascular injury, and prevertebral abscess have all been reported as complications of diagnostic cervical disc injection. Any meaningful assessment of the role of cervical discography in the evaluation of degenerative disc disease must include a determination of the risks inherent in the procedure. We retrospectively analyzed 4400 cervical disc injections in 1357 patients performed by an experienced radiologist between 1988 and 1993 to define the morbidity and mortality associated with discography. In addition, we reviewed the extant medical literature on the complications of this controversial procedure. This study demonstrates significant complications from diagnostic discography procedures occurring in less than 0.6% of the patients and 0.16% of the cervical disc injections.

Intraventricular rupture of a purulent brain abscess: case report.

The mortality of patients with brain abscesses has decreased significantly from 38% in the 1950s to 25% in the 1980s (P = 0.003, Fisher's exact test by decade of report; asymptotic P values based on chi 2 distribution with 3 degrees of freedom, 28 series, 2825 total patients). This decrease in mortality has been attributed to improved diagnostic imaging, the evolution of neurosurgical techniques and understanding of intracranial pressure pathophysiology, greater critical care understanding, and newer antibiotics. However, the mortality associated with the intraventricular rupture of brain abscesses (IVROBA) remained consistently high (at or above 80% once IVROBA was identified) throughout these decades. Although 129 cases (84.5% mortality, 20 survivors) of IVROBA were located in these series and an additional six case reports of survival after IVROBA were found in the literature, treatment advice and detailed clinical description of these surviving cases are sparse or absent. A case of IVROBA with good quality of survival is presented along with the aggressive five-component therapeutic plan used. The five components are: 1) open craniotomy with debridement of abscess cavity, 2) lavage of the ventricular system, 3) 6 weeks of intravenous antibiotics, 4) intraventricular gentamicin twice daily for 6 weeks, and 5) intraventricular drainage for 6 weeks.

Clinical and pathological analysis of spinal cord astrocytomas in children.

Twelve children with pathologically confirmed, well-differentiated spinal cord astrocytomas were studied, and correlations among the degree of resection, pathological characteristics, and time of recurrence were examined. Eight tumors were sampled for biopsy or subtotally resected, and 4 were thought to have been totally removed. Clinical recurrence was seen in 4 of 12 patients, 2 of whom died of their disease. The time to recurrence was 1, 2, 2, and 35 years, respectively. The other 8 children remain free of symptoms, with follow-up ranging from 6 months to 35 years (mean, 8.8 years). In 3 of 8 patients who underwent biopsy or subtotal resection, the tumor recurred, and 2 patients died, whereas there was one recurrence in the patients in whom a "total" resection had been obtained. The histologically well-differentiated nature of the lesions correlated well with the relatively prolonged clinical course seen in this series during the period of observation. The relatively long clinical courses seen in our limited series should be considered before high-risk therapy for spinal cord astrocytomas in children is implemented. The presence of four pilocytic astrocytomas in this group was of special interest, and it seems likely that these discrete neoplasms can be distinguished from the more infiltrating fibrillary astrocytic neoplasms by magnetic resonance imaging with enhancement with gadopentetate dimeglumine.

One-stage anterior cervical decompression and posterior stabilization. A study of one hundred patients with a minimum of two years of follow-up.

One hundred patients were managed with one-stage anterior decompression and posterior stabilization of the cervical spine. The underlying indication for the operation was cervical trauma in thirty-one patients; a neoplasm with a pathological fracture or an incomplete neurological deficit in fifty-five; and a miscellaneous condition, such as infection, rheumatoid arthritis, or cervical spondylotic myelopathy, in fourteen. The duration of follow-up ranged from twenty-four to 108 months (mean, thirty-two months) for the living patients. Sixteen patients had the procedure after the failure of an operation that had been performed elsewhere. The development of more biomechanically rigid cervical instrumentation did not obviate the need for a combined anterior and posterior approach. Twenty-six patients (26 per cent) had supplemental cervical instrumentation as part of the circumferential arthrodesis: seventeen had insertion of an anterior cervical plate and nine had insertion of a posterior facet plate. There were no iatrogenic neurological deficits. Of the seventy-five patients who had had a neurological deficit preoperatively, fifty-one improved one grade and six improved two grades according to the system of Frankel et al. Of the thirty-five patients who had not been able to walk preoperatively, twenty-one regained enough motor strength to walk postoperatively. Because the anterior and posterior procedures were performed during one session of general anesthesia, the prevalence of perioperative complications related to the airway was lower than that previously reported in the literature. No patient had an obstruction of the airway.

Rheumatoid arthritis. Neuroanatomy, compression, and grading of deficits.

STUDY DESIGN: The authors summarize published data regarding cervical spine involvement in rheumatoid arthritis, define the neurologic manifestations, and provide recommendations for management of these complex and difficult problems. OBJECTIVES: The authors attempted to accurately define the neurologic lesions resulting from rheumatoid involvement of the cervical spine despite the complexity of the neuroanatomy of the cervicomedullary region and the diversity of pathology. SUMMARY OF BACKGROUND DATA: Despite the long-standing recognition of cervical spine involvement in rheumatoid arthritis, appreciation of the different neurologic manifestations of this disease has been lacking or misunderstood. METHODS: The authors reviewed the relevant neuroanatomy, neurovascular anatomy, and neuropathologic lesions that interact to create these complex and often confusing clinical situations. RESULTS: Rheumatoid arthritis produces encroachment on the brainstem and cervical spinal cord. The minimum space available at the craniocervical junction for the neural structures is 13 to 14 mm, which is fairly constant. Below C2, the available space is only 12 mm. When the amount of space reduced below this amount, there is, by definition, neural compression. The site of compression and/or repeated microcontusions will determine subsequent neurologic deficits. At the craniovertebral junction, neural compression and traumatic injury typically occur anteriorly at the pyramidal decussation producing cruciate paralysis with considerable weakness in both arms and minimal leg involvement. Cranial settling can result in lower medulla and cranial nerve dysfunction. Subaxial stenosis typically results in a more typical myelopathy. CONCLUSIONS: Accurate diagnostic studies are mandated to determine the location of compression and to fully appreciate the resultant neurologic deficits. To improve more complete comprehension of the neurologic manifestations of rheumatoid arthritis, the relevant neuroanatomy, neurovascular anatomy, and neuropathologic lesions must be understood.

Spinal cord injury. Role of steroid therapy.

STUDY DESIGN: The authors review the evidence supporting the role of glucocorticosteroids in spinal cord injury, critique published studies, and provide recommendations for steroid use in this complex and difficult problem. OBJECTIVES: The authors detail the evolution of the use of glucocorticosteroids for acute spinal cord injury and objectively assess the results of NASCIS I and II. SUMMARY OF BACKGROUND DATA: Glucocorticosteroids were first used in patients with acute spinal cord injury in the 1960s. An initial randomized clinical trial (NASCIS I) did not demonstrate a difference in outcome between the low- and high-dose steroid therapy. A subsequent study (NASCIS II) demonstrated that a treatment could enhance neurologic recovery. METHODS: The authors critically review the preclinical studies of glucocorticosteroids, NASCIS I and NASCIS II: The majority of the critique focuses on NASCIS II and independent analysis of the data generated by that trial. RESULTS: NASCIS II suggests clinical benefit from high-dose intravenous methylprednisolone therapy. The true benefit of steroid therapy is unclear because of the difference in outcome of the two placebo groups who entered the protocol before and after 8 hours. The initial promising results may be negated by the better recovery of the delayed treatment and/or untreated group of patients in the greater than 8-hour placebo group. However, until the raw patient data from NASCIS II is made available for independent review, the actual benefit of intensive steroid therapy will remain elusive. CONCLUSIONS: Even with the controversies and unresolved issues, we advocate initiation of intensive glucocorticosteroid therapy as soon as possible after acute spinal cord injury, and not beyond the first 8 hours. There is too much data available to arrive at any other conclusion.

Measurement of thoracic and lumbar fracture kyphosis: evaluation of intraobserver, interobserver, and technique variability.

STUDY DESIGN: Statistical analysis of various measurement techniques for thoracolumbar burst fracture kyphosis on lateral radiograph. OBJECTIVE: To determine the most reliable measurement technique. SUMMARY OF BACKGROUND DATA: The treatment of thoracic and lumbar burst fractures involves many factors, including the degree of resultant kyphosis. Although various methods have been described, no study has directly compared these methods for reliability and reproducibility. METHODS: Fifty lateral radiographs of thoracic and lumbar burst fractures were randomly selected and measured on two separate occasions by three spine surgeons using five different measurement techniques. Radiograph quality, fracture type, and the center beam location were determined. Statistical analysis included analysis of variance for repeated measures and analysis of variance using a generalized linear model. RESULTS: Intraclass correlation coefficients were most consistent for Method 1 (rho = 0.83-0.94) followed by Method 4 (rho = 0.65-0.89) and Method 5 (rho = 0.73-0. 85). Intraobserver agreement (% of repeated measures within 5 degrees of the original measurement) ranged between 72% and 98% for all techniques for all three observers, with Method 1 showing the best agreement (84%-98%). Paired comparisons between observers varied considerably with interobserver reliability correlation coefficients ranging from 0.52 to 0.93. Method 1 showed the highest interobserver reliability coefficient (0.81, range 0.71-0.93) followed by Method 5 (0.71, range 0.68-0.75). Method 1 also had the highest percentage of agreement within categories (90% within 5 degrees ). CONCLUSIONS: Method 1 (measuring from the superior endplate of the vertebral body one level above the injured vertebral body to the inferior endplate of the vertebral body one level below) showed the best intraobserver and interobserver reliability overall.

The posterior operative approach for cervical radiculopathy.

Cervical disc disease includes acute herniation and chronic disc degeneration with secondary changes in the associated bone. The latter may lead to the spectrum of cervical spondylitic stenosis, which is considered to be multilevel and may be more of a bony disease. Clinically, cervical disc disorders can be divided into several disorders. The disorder of true cervical radiculopathy is associated with lateral compression of the nerve root. When this condition is due to a lateral soft disc herniation or lateral bony stenosis, the posterior cervical laminoforaminotomy is commonly used. It is a procedure that works extremely well in the vast majority of patients and there is no risk of spinal instability; therefore, no fusion is required. The details of operative care have been described. In patients who have persistent radicular problems after a failed anterior cervical interspace procedure, the posterior cervical laminoforaminotomy with posterior wiring and fusion is a simple and effective operative option.

Ganglioglioma: a clinical study with long-term follow-up.

Gangliogliomas are uncommon tumors of mixed neoplastic glial and neuronal elements. Because of their low incidence, few large series exist that fully describe the clinical characteristics of patients afflicted with this tumor. We have reviewed the medical records of 20 patients at Duke University Medical Center with histologically proven gangliogliomas. These patients typically presented within the first three decades of life and their most common presenting symptom was seizures. Therapies included surgical resection, either partial or total, radiation therapy, and/or chemotherapy. Long-term follow-up was achieved by chart review and by telephone interview. Patients who underwent gross total resection alone seemed to fare the best when comparing all treatment groups, and we therefore recommend this as the main form of treatment.

Pneumosinus dilatans: a sign of intracranial meningioma.

BACKGROUND: Pneumosinus dilatans affecting the sphenoid and posterior ethmoid sinuses has been reported in association with spheno-orbital meningiomas and is believed by some authors be a sign of an adjacent meningioma. METHODS: We report the case of a 57-year-old man who developed progressive neurologic signs and symptoms consistent with a frontal lobe lesion. Neuroimaging studies revealed a large partially cystic mass at the base of the anterior cranial fossa that appeared to be invading the left frontal lobe and that was associated with pneumosinus dilatans of the adjacent left frontal sinus. RESULTS: Although the appearance of the mass by neuroimaging was thought to be most consistent with a malignant glioma, the lesion was found at craniotomy to be a benign meningothelial meningioma. CONCLUSIONS: Many previous cases of progressive optic neuropathy associated with pneumosinus dilatans affecting the sphenoid and posterior ethmoid sinuses have been found to be caused by adjacent optic nerve sheath meningiomas. This case provides further evidence that pneumosinus dilatans is a sign of intracranial meningioma.

Evaluation of memory and language function pre- and postthalamotomy with an attempt to define those patients at risk for postoperative dysfunction.

Memory and language dysfunction has been sporadically reported following stereotaxic thalamotomies. In order to determine which patients are at greatest risk and to better define the nature of this dysfunction, we have prospectively evaluated 18 patients undergoing stereotaxic thalamotomies for movement disorders (MDs). Patients were evaluated clinically, with computed tomography (CT) and with memory and language protocols (MLPs) pre- and postoperatively. Patients exhibiting postoperative deficits were again evaluated with the MLP on follow-up visits to the clinic. Significant changes in memory and language function occurred in 7 out of 18 patients. These 7 patients had diverse etiologies for their MDs. Five of the 18 patients had undergone previous thalamotomies on the contralateral side. Three of these 5 patients with bilateral thalamotomies experienced postoperative functional impairments in memory and language while only 4 of 13 patients with a unilateral thalamotomy experienced these problems. The postoperative functional impairments noted were primarily those requiring orientation and speech. All patients with postoperative memory and language impairments were again evaluated with MLPs months after the operation. In 3 of 7 patients, no improvement was noted, while the remaining 4 did recover to baseline. More severe deficits tended to occur in those patients with ventriculomegaly or evidence of other major cerebral tissue loss by preoperative CT scan and in those patients with lower MLP scores preoperatively. Postoperative memory and language dysfunction was not correlated with the number or size of the lesions made, the postoperative general neurologic examination or CT scans, or the clinical response of the MDs. From our data, it appears that patients with more profound neurologic compromise and/or bilateral involvement as evidenced by poor performance on the MLP, tissue loss on CT scanning, or previous thalamic lesion, are most at risk for memory and language dysfunction postoperatively. However, this dysfunction is not necessarily permanent. Preoperative evaluation with MLPs and CT scanning appear to be of value in predicting those patients at greatest risk for postoperative and language dysfunction.

Differentiating lymphocytic adenohypophysitis from pituitary adenoma in the peripartum patient.

Lymphocytic adenohypophysitis (LAH) is an autoimmune disorder of the pituitary gland with a predilection for the peripartum period and often mimics a pituitary adenoma. We sought to define the clinical, endocrinologic and radiographic characteristics differentiating peripartum LAH from pituitary adenoma to enable the use of noninvasive diagnosis and appropriate therapy. From published reports and our own case, the clinical histories and laboratory and radiographic studies of 45 patients fulfilling the diagnosis of peripartum LAH were reviewed. History of infertility or menstrual irregularity, symptomatology, endocrinologic evaluation, diagnostic imaging and associated medical conditions were analyzed. For comparison, 806 patients with pituitary adenoma and pregnancy from published series were evaluated. The spontaneous pregnancy rate in pituitary adenoma patients was 2.4% vs. 100% in LAH patients. Visual disturbances and headaches were significantly more frequent in patients with LAH. Prolactin levels were significantly lower in patients with LAH than in those with pituitary adenomas (34.6 +/- 46.3 [SD] vs. 393.0 +/- 300.4, P < .0001). Abnormalities in thyroid and/or adrenal function were also more common in patients with LAH (57.5% vs. 2.5%, P < .001). There were no distinguishing characteristics on radiographic studies. History and endocrinologic evaluation can differentiate between LAH and pituitary adenoma in the peripartum patient.

Dorsal root entry zone lesions in the treatment of pain related to radiation-induced brachial plexopathy.

Radiation-induced brachial plexopathy (RBP) is a rare (1-2% of irradiated patients) but serious disorder associated with supramaximal irradiation of the brachial plexus. Nerve compression by radiation-induced fibrosis in the absence of tumor recurrence is the hypothesized mechanism of RBP. It appears as severe pain in up to 20% of cases. Current medical and surgical therapies are ineffective in obtaining long-term pain control. Dorsal root entry zone (DREZ) lesions represent a potential therapy for the pain associated with RBP. The records of two patients with RBP with severe pain successfully treated with DREZ lesions are reviewed. Each received supramaximal radiation to the brachial plexus following resection of the malignancy and had pain within the irradiated area approximately 1 year following radiation without evidence of tumor recurrence by either computed tomography or magnetic resonance imaging. Electromyography patterns consistent with RBP were detected within the irradiated area in both patients. Pain was in the C8-T1 distribution and described as sharp and burning. Both patients failed to obtain pain relief with prior medical and/or surgical procedures. Histologic sections of nerves were taken at surgery and confirmed the diagnosis of radiation-induced injury. Within the immediate postoperative period both patients experienced excellent pain relief and continue to be pain free at 29-48-month follow-up observation. The DREZ lesions provide a safe and effective therapy for the pain associated with RBP.

Nucleus caudalis DREZ for facial pain due to cancer.

Five cancer patients underwent nucleus caudalis DREZ operations for medically refractory facial pain. Etiologies included a posterior fossa microglioma, a lacriminal gland carcinoma, a temporal meningioma, a parasellar tumor (craniopharyngioma), and an orbital fibrosarcoma. Postoperative results were graded as excellent (complete pain relief), good (pain decreased, activity not limited), fair (pain present, but less than before surgery, activity limited), and poor (pain same or worse than before surgery). Immediately following surgery, all patients reported good or excellent pain relief. On later followup (mean = 14.4 mo), three of our five patients reported a significant improvement in pain and level of activity. The remaining two patients reported that the pain was less than before surgery but that their activity was still limited because of the pain. We conclude that the nucleus caudalis DREZ operation is useful in treating medically refractory facial pain due to cancer. At this time, it appears that patients with burning pain, no hyperesthesias, and no previous neuroablative procedures have the better chance at a successful outcome.

Trends and complications in cervical spine surgery: 1989-1993.

In an effort to determine trends in surgery of cervical spine disorders and the incidence of complications resulting from this treatment, a mechanism was established for the collection and analysis of multicenter data on an every-5-year basis. This data collection technique allowed the tracking of trends in the treatment for specific diagnoses and determination of complication rates for individual procedures. We present the results occurring in 4,589 patients operated on by 35 surgeons per year between 1989 and 1993. Principal diagnoses included spondylosis, herniated nucleus pulposus, trauma, rheumatoid arthritis, ankylosing spondylitis, ossification of the posterior longitudinal ligament, and tumor. Surgical procedures included anterior cervical discectomy, anterior cervical discectomy and fusion, corpectomy, laminectomies, posterior arthrodesis, laminoplasty, and cervical plating. Complications reported include: bone graft failure, cerebrospinal fluid leak, recurrent laryngeal nerve injury, root injury, quadriplegia, and death. The yearly percentages of each diagnosis have been roughly stable for each year of the study. However, the operative procedures revealed some interesting trends. There was no overall trend with regard to complications over time, and the overall complication risk was approximately 5%. The present data confirm that cervical spine disease is primarily degenerative or discogenic. However, trauma still remains a major part of the practice, accounting for upwards of 17% of reported cases. Anterior procedures were twice as common as posterior ones. The risk of operative complications remains small yet significant.

Primary care for women. Comprehensive assessment of the neurologic system.

This article reviews the essential neuroanatomy and neurophysiology, and summarizes the components of the health history, physical exam, and laboratory tests required for an assessment of the neurologic system within the primary care setting. Brief case studies illustrate the wide range of symptoms associated with neurologic disorders in women and the manner in which the pattern of symptoms can be used to locate the site of pathology and indicate the need for referral and follow-up.

Intracranial metastatic adenocarcinoma of the prostate presenting as visual disturbance.

We report two cases of intracranial metastatic adenocarcinoma of the prostate that presented with visual disturbance. The two patients had no prior history of prostate cancer and both underwent invasive neurosurgical procedures. Progressive neurological decline mandated craniotomy in one patient and the other patient underwent transphenoidal surgery for biopsy. Androgen deprivation therapy was instituted postoperatively for both patients when prostate cancer was determined to be the source of the metastatic lesions.

Clinical applications of pharmacologic therapies for spinal cord injury.

We review the evidence supporting the role of glucocorticosteroids, trilazad, and GM1 ganglioside in spinal cord injury and provide our critique of the published studies, along with our recommendations for pharmacologic therapy for this complex and difficult problem.