Contralateral ventricular dilatation in supratentorial tumors.

The computerized tomographic (CT) scans of 411 patients with supratentorial lateralized tumors were compared with an assessment of their clinical condition. More than one-third of these patients showed dilatation of the contralateral lateral ventricle, which was associated with a lower level of consciousness.

Report of a controlled clinical trial comparing automated percutaneous lumbar discectomy and microdiscectomy in the treatment of contained lumbar disc herniation.

STUDY DESIGN: The results of a randomized controlled trial comparing automated percutaneous lumbar discectomy (APLD) with lumbar microdiscectomy for the treatment of small contained lumbar discal herniations are reported. All patients gave full informed consent and were assessed by an independent observer. Seventy-one patients with radiologically confirmed small contained lumbar disc herniations were randomly assigned to undergo either APLD or lumbar microdiscectomy. All patients were formally assessed by the independent assessor using the Macnab outcome classification at 3 weeks, 2 months, and 6 months after the procedure with follow-up being continued for the duration of the study. OBJECTIVE: The objective was to complete the first randomized and blinded study with sufficient numbers to provide a valid statistical evaluation of these procedures. SUMMARY OF BACKGROUND DATA: No previous randomized controlled study comparing these methods has been previously reported. METHODS: Each procedure was performed by the same surgeon using standard techniques. Statistical analysis was by the chi-square method. RESULTS: In the APLD group only 9 of 31 (29%) had satisfactory outcomes as compared to 32 of 40 (80%) for the microdiscectomy group. Of those patients in the APLD group who had an unsatisfactory outcome and who then opted to undergo surgery (20 of 22 patients), the final success rate was only 65%. Thus, the cumulative success rate of the group initially randomized to APLD including those undergoing either APLD alone or APLD and microdiscectomy after unsuccessful APLD was 22 of 31 (71%). CONCLUSION: In this group of patients, APLD is seen to be ineffective in the treatment of contained lumbar disc herniation.

A 10-year follow-up of the outcome of lumbar microdiscectomy.

STUDY DESIGN: A retrospective analysis of the outcome of lumbar microdiscectomy, with independent assessment of outcome. OBJECTIVES: To explore whether the initial positive outcome after microdiscectomy is maintained at long-term follow-up. SUMMARY OF BACKGROUND DATA: Previous reports on long-term outcome after lumbar disc surgery give conflicting messages about whether an initially positive surgical outcome is maintained throughout a 10-year period. This is partly due to differing methods and the failure to include initial outcome, thereby permitting assessment of possible deterioration in the quality of outcome. METHODS: This study presents the initial and long-term outcome after lumbar microdiscectomy, with an independent assessment of outcome. Eighty-eight consecutive patients undergoing lumbar microdiscectomy were identified. Assessment at 10 years after surgery was obtained in 79 (90%) of the cases. The initial outcome was assessed retrospectively by an independent observer at 6 months after surgery using the Macnab classification. The final outcome Macnab classification was completed by postal questionnaire by the patients themselves, who also completed a modified Roland-Morris disability questionnaire. RESULTS: A successful outcome at 6 months was achieved in 91% of the cases. At 10-year follow-up, this result declined slightly to an 83% success rate. However, there was no statistically significant difference between these outcome results. The long-term Macnab classification results correlated well with disability, as measured by the Roland-Morris score. Patient satisfaction with the results of microdiscectomy 10 years later was high. CONCLUSIONS: Lumbar microdiscectomy achieves a high level of initial success, and this positive outcome is maintained at a 10-year follow-up.

Computer-assisted (axial) tomography in the management of subarachnoid haemorrhage.

A prospective trial of the role of routine computer-assisted (axial) tomography of the brain (CT) in the early management of subarachnoid haemorrhage is reported. A correct aetiological diagnosis was made from the CT scan in 76% of patients. Early routine performance of CT frequently provides valuable information in planning management.

Oropharyngeal morbidity following transoral approaches to the upper cervical spine.

The transoral approach to the upper cervical spine is now well established. Oropharyngeal complications have not previously been critically assessed. In the present study, the overall complication rate was 31.6%. This dropped to 15.4% in those patients who did not undergo splitting of the soft palate. The complication rate of 75% in the split soft palate group means that this procedure should be discontinued where it is not absolutely necessary.

Magnetic resonance image findings in the early post-operative period after anterior cervical discectomy.

If early neurological deterioration occurs following anterior cervical discectomy, the patient should be evaluated by urgent MRI scanning. In order to interpret such a scan it is essential to know what the normal post-operative MRI appearance is following an uncomplicated procedure. In the lumbar spine it is well recognized that early post-operative imaging following discectomy is difficult to interpret with a high rate of false positive scans. The normal appearance of MRI in the early post-operative period was evaluated prospectively in 15 patients undergoing anterior cervical discectomy without fusion for either cervical radiculopathy or myelopathy. MRI was performed on the first post-operative day, at 6 weeks and 6 months. The successful outcome of the procedure was validated by uniform improvement of Visual Analogue Scale measurement for neck and arm pain, the Neck Disability Index and European Myelopathy Score as appropriate. In contrast to the established findings following lumbar discectomy, only two cases showed a persistent epidural mass in the first post-operative scan and this had completely resolved at 6 months. All patients had foraminal narrowing and root or cord compression pre-operatively. Sixty six percent of cases showed persistent foraminal narrowing on sequential imaging up to 6 months despite showing good symptomatic improvement. All cases demonstrated high signal in the operated disc space on T2 weighted imaging on the first post-operative day and this finding persisted in 13 of 15 scans performed at 6 weeks. Post contrast imaging demonstrated no enhancement of operated disc space and adjacent vertebral body on the first post-operative day, whereas all scans at 6 weeks showed enhancement and such enhancement persisted at 6 months in 50%. Persistent epidural filling defects are uncommon following successful anterior cervical discectomy but persistence of foraminal narrowing is common despite successful outcome. Enhancement of the disc space is also common and does not in itself imply infection.

Outcome predictors and complications in the management of intradural spinal tumours.

The results of the management of 115 patients with intradural spinal tumours are presented. Data was collected retrospectively from the case notes. Tumours were categorized as intramedullary or extramedullary for statistical analysis. Meningioma, schwannoma and ependymoma accounted for 70% of tumours. Complete macroscopic excision was achieved in 84% of extramedullary and 54% of intramedullary tumours. There were two post-operative deaths, one of which was secondary to methacillin-resistant staphylococcus aureus (MRSA) meningitis. Cerebrospinal fluid leak (10%) and meningitis (7%) were the commonest complications. Ninety-six percent of patients with extramedullary tumours improved or remained unchanged on the Frankel scale. In the intramedullary group, 82% remained unchanged or improved after treatment. Pre-operative functional status was a predictor of good post-operative function for intra- and extramedullary tumours and for intramedullary tumours a good post-operative Frankel score predicted long-term survival.

The role of vertebral body collapse in the management of malignant spinal cord compression.

The management of malignant spinal cord compression has been reviewed recently and attention drawn to the adverse effects of laminectomy. Data from that review suggested that the presence of vertebral body collapse could have an important negative effect on the outcome of laminectomy. However, there was only scant evidence available in the literature to support that conclusion. Eighty consecutive patients with thoracic spinal cord compression due to a single metastasis treated by laminectomy are reported here. It is seen that the presence of vertebral collapse signified: a much reduced chance of regaining the ability to walk; a much greater possibility of further neurological deterioration; and a major increase in the incidence of post-operative spinal instability. The role of laminectomy in the management of such patients needs to be further questioned and alternative therapeutic measures such as radiotherapy, posterior spinal instrumentation or anterior surgery should be strongly considered in the presence of vertebral body collapse.

Adverse effects of the management of malignant spinal cord compression.

As a prelude to further work which attempts to improve the management of metastatic spinal cord compression the efficacy and adverse effects of existing therapy has been assessed. All papers dealing with the management of malignant spinal cord compression since 1960 have been reviewed. Data from this review is presented in a novel manner in order to identify not only the degree of successful return to ambulation achieved but more importantly the extent of the adverse effects which occur during existing management. It is seen that, while in general some 35% of patients treated in any manner retain or return to the ability to walk, some 20% to 25% sustain major neurological deterioration. In addition, those patients treated by laminectomy who do deteriorate may be subject to a significant rate of perioperative mortality and major structural complications related to the surgical wounds. In the light of the adverse factors described, the role of laminectomy as first-line management of malignant cord compression is questioned. Alternative modes of treatment are discussed and a tentative scheme of management described which it is hoped will lead to a better quality of survival of the group as a whole in addition to maintaining, or perhaps, improving the rate of successful return to ambulation.

Management of spinal secondary tumours.

Increasing interest in the problems of managing patients with metastatic spinal disease has resulted not only in major changes in management but also in improvements in outcome. This article reviews these changes and stresses that the most important factor in improving outcome remains early diagnosis.

Dysraphic problems in the lumbar spine: dilemmas in management--a review of 49 cases.

Occult spinal dysraphism can present in many ways. In this review the clinical features, pathology, and management of 49 adult and pediatric cases are discussed. Most recent papers agree that surgery should be performed for clinical deterioration, and many now advise prophylactic surgery for stable or asymptomatic patients. This paper questions the role of prophylactic surgery in such patients. The natural history of occult dysraphism is not known, particularly in the case of adult or asymptomatic patients A conservative management policy, with operation reserved for subsequent clinical or electrophysiological deterioration, is still acceptable in stable or asymptomatic patients. The prospective study of cohorts of patients, with the various forms of occult spinal dysraphism, from units with differing management policies, will help to clarify the natural history of this condition and whether this may be influenced by prophylactic surgery.

Thoracic spinal stenosis in two brothers due to vitamin D-resistant rickets.

X-linked hypophosphataemic vitamin D-resistant rickets is a rare cause of spinal canal stenosis. Two brothers with this condition presented in adulthood with thoracic myelopathy due to spinal canal stenosis. Both were treated by laminectomy using diamond-tipped burrs, with symptomatic improvement.

The role of needle biopsy in the management of malignant spinal compression.

With the changing management of malignant spinal cord compression there has been a reduction in numbers of patients treated by conventional laminectomy. This has resulted in a move either to the use of radiotherapy or to the use of more major surgical procedures such as the transthoracic approach. In both of these situations a more logical approach to deciding on the treatment modality to be used can be achieved by determining the histology of the lesion by percutaneous needle biopsy. This paper describes the technique of needle biopsy and presents evidence that shows that a reliable and immediate diagnosis can be achieved by the use of smear histology.

Can hindbrain decompression for syringomyelia lead to regression of scoliosis?

Scoliosis in childhood develops secondary to syringomyelia in some children. The existing literature does not provide a clear answer as to whether surgical treatment of the syrinx can allow subsequent improvement of the spinal deformity, thus preventing the need for scoliosis surgery. This series comprised 16 patients with syringomyelia who presented with significant scoliosis in the absence of major neurological deficit. All underwent a hindbrain decompression, and follow-up ranged from 1 to 6 years (mean 2.5 years). Subsequent deformity surgery was necessary in eight cases, but the scoliosis was seen to improve or arrest its progression in six (37.5%). Improvement was found to be statistically more likely in children of younger age at the time of syrinx surgery and in those with left thoracic curves. Improvement occurred in 71.4% of those under the age of 10 at the time of hindbrain decompression.

The value of MR imaging in differentiating between hard and soft cervical disc disease: a comparison with intraoperative findings.

The aim of this study is to assess the accuracy of MRI alone in the differentiation of soft cervical disc protrusion from osteophytic compression in cervical disc disease. In a retrospective study, the MRI scans of 41 patients with cervical disc disease, who had previously undergone surgery, were presented to three independent observers, randomly on two different occasions, to identify the accuracy of the diagnosis of the presence of hard or soft disc or both as a cause of compression. The observers (two neurosurgeons and one neuroradiologist) were not involved with the treatment of the cases at any stage and were unaware of the surgical findings. Their observations were compared with those of the surgeon recorded at operation. The intra-observer agreement was poor for diagnosis into three categories as hard or soft disc or both. In distinguishing between the presence or absence of hard disc, there was moderate to good (Kappa = 0.6) intra observer and fair to moderate (Kappa = 0.4) interobserver agreement. The sensitivity of diagnosis of a hard disc was high (87%) but specificity was low (44%), due to the overestimation of the presence of hard disc. There was a significantly higher incidence of hard disc in the elderly age group (76% over the fifth decade, P = 0.0073). It is concluded that MRI alone is not a very efficient diagnostic tool in distinguishing between hard and soft disc in the cervical disc disease.