Spinal cord injury. The role of vascular damage in the pathogenesis of central hemorrhagic necrosis.

We postulated that damage to the endothelial lining of the spinal cord vasculature is a major factor in the pathogenesis of the characteristic lesion of the spinal cord (progressive, central, hemorrhage necrosis) that occurs after acute trauma. Endothelial damage may occur as a result of primary injury to the vessels or after arterial spasm. This damageresults in deposition of platelets and formation of thrombi on the exposed subendothelial tissues and embolization of such thrombi to smaller vessels of the spinal cord parenchyma.

Aggressive multimodality therapy based on a multicompartmental model of glioblastoma.

Glioblastoma multiforme is composed of multiple cellular compartments with different morphologic, kinetic, metabolic, vascular, and genetic properties. Optimal therapy may consist of a variety of therapeutic strategies designed for individual compartments, administered in close temporal relation. These concepts may turn out to be valid for other solid tumors as well. Microwave-induced hyperthermia can be used to treat metabolically quiescent, relatively hypoxic, nondividing cells (Go) otherwise resistant to radiation and chemotherapy. Similarly, polychemotherapy can treat a broad spectrum of cell types if the blood-brain barrier can be circumvented. Radical surgery, repetitively applied, can be safely used to "set up" experimental agents if the operation microscope and laser are employed. A consecutive series of 74 adult patients with malignant astrocytoma were treated with primary resection, radiation therapy, and 1,3,-bis(2 chloroethyl) 1 nitrosourea chemotherapy. At recurrence, all patients were offered reoperation with the microscope and the laser prior to administration of phase-I agents--hyperthermia via an implantable miniature microwave antenna (6 cases); aziridinylbenzoquinone chemotherapy (13 cases); and blood-brain barrier reversal with dimethyl sulfoxide (DMSO) and polychemotherapy (9 cases). It was concluded that temperatures of 45 degrees C could be safely achieved and human tumors could not efficiently dissipate heat; that DMSO plus drug therapy could be tolerated but blood-brain barrier reversal demonstrated by us in animals could not be shown in humans; and that aggressive multimodality therapy and reoperation could produce a 40% 2-year survival rate for patients younger than 40 years.

Alterations in neurological function in head-injured patients experiencing major episodes of sepsis.

More than 300 head injuries per year are evaluated by the neurotrauma team at the Maryland Institute of Emergency Medicine. Although most of the injuries follow motor vehicle accidents, a significant number also follow industrial accidents or acts of personal violence. Approximately 25% of patients with serious head injuries have associated episodes of sepsis--commonly because of other bodily injuries. We have identified a syndrome characterized by encephalopathy and/or accentuation of focal neurological dysfunction in head injury patients that presents during episodes of sepsis and that occurs in the absence of meningitis. Aggressive fever management alone does not reverse the encephalopathy. Neurodiagnostic studies reveal no focal changes. The intracranial pressure often remains normal or unchanged, and no improvement is evident after the empirical administration of standard doses f steroid or osmotic agents. The patient's neurological condition returns to base line once the sepsis has been eradicated. Ongoing investigations suggest an immunological basis for this abnormality.

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.

Minimyelogram in cervical spinal cord trauma.

Fifty-eight patients with a clinical or radiographic diagnosis of cervical spinal cord injury underwent Pantopaque myelography on an emergency basis. Twenty-five per cent of these patients demonstrated evidence of spinal cord compression after reduction by spinal traction, as evidenced by the presence of a myelographic defect. Less than half of these patients had a defect that the authors thought required emergency surgical decompression. Two of the five patients so operated upon demonstrated an improvement in neurological function after operation that was much greater than that which would have been predicted before operation. The finding of these few patients who made a significant improvement after operation may justify the myelographic investigation of all patients with evidence of serious cervical spinal cord injury. Based on our experience, Pantopaque myelography may offer adequate, accurate, and useful information for the immediate management of spinal cord-injured patients.

Calculated recovery rates in severe head trauma.

In a series of 120 head-injured patients, recovery rates (rr) were calculated separately on the basis of either Glasgow come scale (GCS) scores or Maryland coma scale (MCS) scores; the latter contains the three variables of the GCS, excludes unevaluable responses, and provides more information concerning the status of brain stem reflexes and motor lateralization. The early (Day 3/4 vs. Day 1) and late (Day 8/14 vs. Day 1) recovery rates from the two scales generally agree (r = 0.76; r = 0.79), but in 39 of 94 patients the MCSrr and GCSrr disagreed by more than 10%. When the MCSrr was greater than the GCSrr, it more accurately reflected a favorable outcome. Graphic representations of clinical courses through serial plots of raw scores were more reliable when unaffected by intubation, sedation, swollen eyelids, casts, etc.; this was more often achieved with serial plots of MCS scores, which are graded as percentages of testable function. Final outcomes (good/disabled vs. vegetative/dead) were well predicted by Day 1 MCS scores above or below 35% (chi 2 = 27.63; p less than 0.001) and Day 1 GCS scores above or below 7 (chi 2 = 23.21; P less than 0.001). However, in 57 very sick patients (Day 1 GCS less than or equal to 7), the GCS did no better than chance (26 good, 31 bad outcomes), whereas 20 of 26 patients with a Day 1 MCS score of less than or equal to 35% had bad outcomes. In patients with severe multiple injuries, the Maryland coma scale may provide a more sensitive index of clinical course; a Day 1 MCS raw score of less than or equal to 35% is of grave prognostic significance.

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.

Bilateral facet to spinous process fusion: a new technique for posterior spinal fusion after trauma.

A variety of options exist for the treatment of fracture/dislocation of the cervical spine, including prolonged traction immobilization, immobilization in an external device, and open surgical fusion. In cases of facet dislocation and flexion/compression injuries, the authors have found that surgical fusion is the most useful. However, in cases of facet fracture or disruption of the posterior neural arch, routine interspinous wiring techniques do not provide adequate rotational stability and may allow postsurgical redislocation before bony fusion. For these cases, a new technique using bilateral facet to spine wire loops has been developed. In the 25 cases reported here, the technique provided excellent stability against anterior horizontal displacements and rotational dislocations despite unilateral or bilateral facet fracture or disruption of the posterior neural arch.

Effect of age and reoperation on survival in the combined modality treatment of malignant astrocytoma.

Before the advent of the operating microscope and the carbon dioxide laser, reoperations were performed in less than 5% of patients with malignant astrocytoma. Between 1978 and 1981, a consecutive series of 74 adult patients were prospectively treated therapy, all patients eligible for further treatment were offered reoperation with the microscope and/or laser before treatment with Phase I agents (microwave hyperthermia, dimethyl sulfoxide (DMSO)-Adriamycin, DMSO-Cytoxan, or azaridinylbenzoquinone (AZQ)). Forty-six per cent of the patients were referred from outside institutions for intensive treatment. In 36 months, 40 patients received second operations directed at their tumor and had a median calculated survival from the time of reoperation of 37 weeks. The length of survival after the second operation was independent of patient age, performance status, tumor grade, and interoperative interval. Sixty-five per cent of patients under 40 and 48% of patients over 40 underwent reoperation with minimal morbidity and no deaths. The single most important prognostic factor for survival in both reoperated and single-operated patients was age. Tumor grade had no influence on survival in the series as a whole, in patients under 40 years of age, or in reoperated patients. The calculated median survival for the entire series was 15 months, with a predicted 2-year survival rate of 0.25. These figures include all patients treated without exclusion for incomplete radiotherapy or chemotherapy. It is concluded that reoperation for malignant astrocytoma is safe, feasible, and of potential benefit in combination with other therapies. The routine use of reoperation to "set up" other treatment modalities deserves further study.

Effect of intracranial pressure monitoring and aggressive treatment on mortality in severe head injury.

During 1977-1978, 127 patients with severe head injury were admitted and underwent intracranial pressure (ICP) monitoring. All patients had Glasgow Coma Scale (GCS) scores of 7 or less. All received identical initial treatment according to a standardized protocol. The patients' average age was 29 years; 60% had multiple trauma, and 35% needed emergency intracranial operations. Treatment for elevations of ICP was begun when ICP rose to 20 to 25 mm Hg, and included mannitol therapy and drainage of cerebrospinal fluid (CSF) when possible. Forty-three patients (34%) had ICP greater than or equal to 25 mm Hg; of these, 36 (84%) died. The mortality rate of the entire group was 46%. During 1979-1980, 106 patients with severe head injury were admitted and underwent ICP monitoring. Their average ager was 29 years; 51% had multiple trauma, and 31% underwent emergency intracranial surgery. All patients received the same standardized protocol as the previous series, with the exception of the treatment of ICP. In this present series: if ICP was 15 mm Hg or less (normal ICP), patients were continued on hyperventilation, steroids, and intensive care; if ICP was 16 to 24 mm Hg, mannitol was administered and CSF was drained; if ICP was 25 mm Hg or greater, the patients were randomized into a controlled barbiturate therapy study. Twenty-six patients (25%) had ICP's of 25 mm Hg or greater, compared to 34% in the previous series (p less than 0.05), and 18 of these 26 patients (69%) died. The overall mortality for this current series was 28% compared to 46% in the previous series (p less than 0.0005). This study reconfirms the high mortality rate if ICP is 25 mm Hg or greater; however, the data also document that early aggressive treatment based on ICP monitoring significantly lessens the incidence of ICP of 25 mm Hg or greater and reduces the overall mortality rate of severe head injury.

Evoked potentials in the clinical neurosciences.

The use of evoked potentials for the evaluation of disorders of the nervous system has become a most valuable aid to the neurosurgeon and neurologist, often providing information of critical value without recourse to invasive techniques. In order to employ these techniques, it is helpful to understand the principles of evoked potential electrogenesis and the methodology used for analysis of evoked potential clinical data. This article is aimed at providing the clinical neurosurgeon with this type of information and with a review of current clinical applications in this rapidly developing field.

Multiple cranial nerve palsies due to a hyperextension injury to the cervical spine. Case report.

The case of a patient with multiple bilateral cranial nerve palsies and spinal cord sparing secondary to a stable hyperextension injury to C-1 is presented.

Steroids in severe head injury: A prospective randomized clinical trial.

This is a prospective randomized study of the efficacy of steroid therapy in patients with severe head injury. One hundred patients were randomized into two equal groups: the steroid group received 5 mg/kg/day of methylprednisolone, and the nonsteroid group received no drug. The groups were similar in their clinical features. All patients received a standardized therapeutic regimen. The patients were also classified as early responders or nonresponders to the overall treatment protocol without regard to steroid administration, on the basis of change in Glasgow Coma Scale score during the first 3 days of admission. There was no statistically significant difference in the outcome of the steroid and nonsteroid group at 6 months. Of the responders who were on steroids, 74% had good outcomes or were disabled, compared with 56% of the responders who did not receive steroids. In the nonresponder group, the patients on steroids were actually associated with a worse outcome than those who did not receive steroids: 75% of the nonresponders who received steroids were dead or vegetative, compared to 56% of those who were not receiving steroids. The data suggest that: 1) the effect of steroids may be different for different patient groups; 2) in order to identify these patients, a sensitive coma scale is needed; and 3) a rational approach to steroid therapy in head-injured patients may be to start all patients on steroids, but to discontinue their use in patients identified as not benefiting from steroid therapy.

Wide variation in risk of wound infection following clean neurosurgery. Implications for perioperative antibiotic prophylaxis.

The authors have prospectively examined the occurrence of postoperative wound infection following clean neurosurgery in 936 patients. Fewer than 1% received perioperative antibiotic prophylaxis. The overall rate of deep wound infection was 2.6%; no deaths were directly attributable to these infections. Deep wound infections occurred significantly more frequently following craniotomy (4.3%) than following spinal (0.9%) or other clean neurosurgery. Among craniotomies, the deep wound infection rate varied significantly from 11% following repeat operations for recurrent gliomas to 2.5% following non-tumor surgery. Risk of deep wound infection varied more than 11-fold depending on the type of clean neurosurgical operation. It is most feasible to demonstrate the potential efficacy of perioperative antibiotics in clean neurosurgical procedures with the greatest risk of postoperative wound infection. The potential benefit from such prophylaxis would be greatest for patients undergoing these high-risk operations.

Intradural cervical disc herniation and Brown-Séquard's syndrome. Report of three cases and review of the literature.

Although cervical disc herniation commonly requires surgical intervention, the intradural sequestration of a herniated cervical disc fragment is rare. In searching the world literature on this topic, the authors found six case reports. They report three new cases of intradural cervical disc herniation in which the patients presented with Brown-Séquard's syndrome and they review the literature. Although Brown-Séquard's syndrome is a rare clinical finding in extradural disc herniation, six of the nine patients with intradural cervical disc herniation (our cases and those from the literature) presented with symptoms of this syndrome. The remaining patients presented with para- or quadriparesis. This suggests that intradural disc herniation should be considered preoperatively in patients in whom there is magnetic resonance imaging or myelographic evidence of cervical disc herniation and Brown-Séquard's syndrome. In patients who underwent anterior cervical discectomy for the treatment of intradural cervical disc herniations, better outcomes were demonstrated than in those in whom posterior procedures were performed.

Myelotomy for control of mass spasms in paraplegia.

A new myelotomy knife is described and a procedure, designed to sever certain reflex connections while preserving as many corticospinal connections as possible, is presented. Through intermittent dorsal midline incisions the gray matter lateral to the central canal is severed bilaterally under the microscope from L-1 to S-1. This procedure relieved mass spasms and hyperactive reflexes in 14 paraplegic or tetraplegic patients, but preserved postural reflexes and whatever voluntary motor power the patients had prior to myelotomy. Before myelotomy all patients were bedridden. Afterward nine patients were able to use a wheel chair and five were able to walk with the use of parallel bars or crutches.

Adverse reactions to intrathecal saline injection for control of pain.

The authors report the results of a questionnaire regarding the use of hypertonic saline for the control of pain. Of 2105 patients so treated, nearly 11% had an adverse temporary symptom or sign, reported as an untoward reaction; slightly over 1% suffered a significant morbidity, of which paraplegia or quadriplegia was by far the most common, and two patients died (0.1%).

Estrogen and progesterone receptors in meningiomas.

Two-thirds of all meningiomas and four-fifths of intraspinal and sphenoidal meningiomas occur in women. Meningiomas frequently enlarge or become symptomatic during pregnancy or during the luteal phase of the menstrual cycle. There is an increased incidence of meningiomas in women with breast carcinoma. In a series of 23 patients with meningiomas, the authors assayed biopsy specimens of the tumor for the presence of estrogen (ER) and progesterone (PR) receptors, using glycerol density gradient centrifugation and dextran-coated charcoal techniques. Significant levels of ER were found in only 17% of the patients, while significant PR levels were detected in 39%. Only one of the 16 tumors from female patients had significant ER levels, whereas three of the seven tumors from men had significant ER levels. Eight of the 16 tumors in women had significant PR levels, whereas only one of the seven tumors in men had a significant PR level. Thus, three out of four tumors with definite ER were from men, whereas eight of nine tumors with definite PR were from women. Of the eight women whose tumors contained PR, three were premenopausal and five postmenopausal. The single tumor with high levels of PR in the male patient was histologically atypical. The results of this series were compared with six published series of sex steroid assays in meningiomas. These seven series were divided into two groups: one group included two reports from the same laboratories in France, and the other the remaining five reports. Much higher percentages of both ER- and PR-positive tumors were reported from the French group. The authors suggest that this discrepancy may be due to the use of preoperative glucocorticoid therapy in the series from the United States. Since meningiomas are known to enlarge during periods when levels of circulating progestins are high, the presence of significant quantities of PR in a high percentage of tumors may have therapeutic implications for recurrent, malignant, or incompletely excised tumors, or for medically fragile patients. Conversely, since meningiomas are not known to enlarge during the proliferative phase of the menstrual cycle or with exogenous estrogen therapy, the small number of tumors positive for ER may indicate that ER lacks clinical significance. High levels of PR found in a small group of histologically aggressive tumors in several series may indicate that hormonal therapy may be especially useful in this difficult subset of patients.

Magnetic resonance imaging documentation of coexistent traumatic locked facets of the cervical spine and disc herniation.

The coexistence of traumatic locked facets of the cervical spine and a herniated disc is not well described. The authors present a series of patients with traumatic locked facets who demonstrated a high incidence of associated disc herniation documented on magnetic resonance (MR) imaging. Thirteen patients with either unilateral (four cases) of bilateral (nine cases) locked facets of the cervical spine were analyzed retrospectively. Immediate closed reduction using traction and/or manipulation was attempted in the first nine cases treated and was successful in only three; however, the procedure was abandoned in three cases due to deterioration in the patient's clinical status. In the subsequent four patients, an MR image was obtained prior to attempts at closed reduction. All patients underwent MR imaging of the cervical spine. Of eight consecutive cases treated at the University of Michigan, frank disc herniation with fragmented disc in the canal was found in five while pathological disc bulging was found in the other three. All five cases contributed by other institutions had concurrent disc herniation. This series illustrates the importance of using MR imaging to document the presence of a herniated disc during the initial evaluation of a patient with traumatic locked facets of the cervical spine and prior to attempted reduction of the locked facets. Experience indicates that closed reduction of facet dislocation associated with disc rupture may result in increased spinal cord compression and neurological deficit. If a herniated disc is discovered, anterior discectomy and fusion would be favored as the initial therapy over attempts at closed reduction or operative posterior reduction.

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.