Resolution of spontaneous spinal epidural hematoma without surgery: report of two cases.

STUDY DESIGN: Case report. OBJECTIVE: To report two cases of spontaneous spinal epidural hematoma that completely resolved, clinically and radiographically, without surgical treatment. SUMMARY OF BACKGROUND DATA: The treatment of spinal epidural hematoma is usually surgical. Spontaneous spinal epidural hematoma is an uncommon phenomenon and may be of uncertain cause. METHODS: One patient with acute onset of complete quadriplegia and another with complete paraplegia caused by spontaneous spinal epidural hematoma were treated without surgery. RESULTS: Both patients recovered nearly completely with respect to their neurologic function at 3-month follow-up. No source of hematoma was ever identified. CONCLUSIONS: Spontaneous spinal epidural hematoma should be considered in the differential diagnosis of sudden onset of spinal cord compression in association with back pain. Patients initially presenting with severe neurologic dysfunction are potential candidates for conservative management if they demonstrate rapid and progressive improvement in neurologic function. Patients treated in this manner can have nearly complete restoration of function.

Giant intraspinal pseudomeningoceles cause delayed neurological dysfunction after brachial plexus injury: report of three cases.

OBJECTIVE AND IMPORTANCE: Delayed neurological dysfunction after a brachial plexus injury is uncommon. We present the cases of three patients with a history of significant brachial plexus trauma and late neurological deterioration secondary to giant intraspinal extradural pseudomeningoceles. CLINICAL PRESENTATION: Three patients, each with a remote history of brachial plexus trauma, presented with slowly progressive upper-limb weakness. An examination revealed bilateral lower motor neuron weakness in the upper extremities in all patients and evidence of spastic paraparesis in one. Magnetic resonance imaging and postmyelogram computed tomographic scans demonstrated large anterior extradural cerebrospinal fluid collections extending from the upper cervical to lower thoracic and lumbar levels in each patient. Myelograms demonstrated a connection with the subarachnoid space in two patients. INTERVENTION: Direct obliteration of the connection between the cyst and the subarachnoid space was completed in two patients, and a cystoperitoneal shunt was placed in the third. Postoperative imaging demonstrated complete resolution of the extradural collections. Arrest of progression of upper-limb deterioration was observed in all patients, and dramatic improvement of long tract symptoms occurred in one. CONCLUSION: Giant intraspinal pseudomeningoceles are a rare complication of brachial plexus root injuries or avulsion, capable of causing significant morbidity. Early intervention can improve symptoms related to long tract involvement and prevent further deterioration of lower motor neuron disease. The pathophysiology of neurological dysfunction caused by these giant collections is unclear; however, vascular and mechanical factors thought to be important in the pathogenesis of cervical myelopathy also may have a role.

Experimental use of somatosensory evoked potential for intraoperative identification of spinal cord blood supply.

The role of sensory evoked potentials (SEPs) to be used intraoperatively to reliably predict spinal cord ischemia, caused by interruption of intercostal and of lumbar and sacral arteries, was evaluated in a canine model. Two groups were assessed: (A) interruption of intercostal arteries (n = 6) and (B) interruption of all posterior branches (n = 6). SEPs were evaluated intraoperatively as control and interruption of posterior vessel groups, and at 18-22 h after surgery. Neurologic assessment was performed preoperatively and 18-22 h postoperatively by modified Tarlov criteria. Morphological assessments were also performed. The assessment of the groups demonstrated prolongation of latency and loss of amplitude of SEP, but individual changes of SEPs were poor predictors of paraplegia. Ultrastructural changes correlated with neurologic findings. SEPs were unreliable for intraoperative identification of vessels critical to spinal cord blood supply, possibly related to anatomically different blood supply of sensory and motor tracts.

Fractured odontoid: the management of delayed neurological symptoms.

Undiagnosed and untreated odontoid fractures are relatively common in developing countries where treatment for minor injuries is not considered. As a result, patients frequently present with neurological deterioration secondary to delayed odontoid dislocation. Fifty-one consecutive patients with this problem were entered into a management protocol and reviewed for this report. After diagnosis, reducibility was analyzed by extension films, and all patients who could not be reduced were initially managed in cranial long traction. Thirty-seven were reduced spontaneously or by traction alone, and 12 required transoral decompression. All underwent posterior C1-C2 fusion. Postoperatively, all were treated in external orthoses. The neurological recovery was excellent in 34 patients. Seven patients could function but had some disability, three patients had disabling spasticity, and three remained bedridden. Four deaths occurred as a result of respirator-dependent patients being taken home for social and financial reasons. As a result of this case-controlled study, we recommend that the treatment protocol first analyze reducibility by extension x-rays and then try traction for as long as 14 days to attempt reduction in patients who did not reduce in extension. Failure of reduction is indication for transoral decompression, and all patients require C1-C2 fusion. The neurological recovery is related to initial impairement but can be satisfactory in > 75% of patients.

Features of spinal cord injury in Taiwan (1977-1989).

In order to establish an etiological and statistical base for spinal cord injuries, 1,617 spinal cord injured patients admitted to the Chang Gung Memorial Hospital in Taiwan during the period of 1977 to 1989 were reviewed. The most common causes of injury were pedestrian (29.31%) and motorcycle (28.88%) accidents. The greatest incidence of injury was in the 26-35 year age group. The complete tetraplegic patients had the highest mortality rate (26.5%). Additional features studied were the time of occurrence and pattern of injury. Information gathered from this study suggest the need to establish a Spinal Cord Injury Prevention Program, to develop a Prehospital Care System and set up comprehensive Spinal Cord Injury Units in Taiwan. We expect this study to be adaptable to other similar developing countries.

Evaluation of the operating room as a surgical teaching venue.

Surgical educators are facing changes in residency training that have a direct impact on the opportunity that surgeons and residents have for clinical teaching and learning. The knowledge required of residents continues to escalate. Further, as resident positions are reduced, the opportunity for inter-resident education is decreased. Increased service-to-education ratios may result in resident discontent unless surgeons take an active role in the resident's educational experience. The purpose of this study was to examine the educational activities that occur during the operating-room experience. Technical training in the procedure being done was the primary educational activity, but there were long periods when no form of education was taking place. The operating room provides the teacher and learner with uninterrupted time together, and this time can and should be used for clinical teaching and learning.

Testosterone-related exacerbation of a prolactin-producing macroadenoma: possible role for estrogen.

Men with PRL-producing macroadenomas often present with hypogonadism and impotence. This report documents exacerbation of a PRL-secreting tumor after two separate 200-mg testosterone enanthate (T) injections despite continued bromocriptine (BRC) therapy. A 37-yr-old man with a 60-mm invasive tumor and a serum PRL level of 13,969 +/- 332 ng/ml (mean +/- SD) responded to BRC therapy with rapid disappearance of visual field defect, headache, and facial pain as well as decrease in serum PRL to 5,103 +/- 1,446 ng/ml. T injection was followed by severe headache, facial pain, and increase in PRL to 13,471 ng/ml. Visual field deterioration and increased tumor size (height, 40-43 mm) by computed tomography were documented. A relationship between T injection and exacerbation of the prolactinoma was not recognized until after a second T injection 3 months later. After that therapy, baseline PRL increased from 6,900 to 12,995 ng/ml. The hypothesis that T was aromatized to estradiol, directly stimulating lactotrophs, was supported by an increase in serum estradiol from 24 to 51 pg/ml after the second T injection. Although T treatment is accepted as appropriate therapy for hypogonadism in men with prolactinomas, it may not only interfere with the response of the tumor to BRC therapy, but even stimulate tumor growth and secretion.

International education: a third alternative.

Education is the key to the delivery of medical care in the developing world. The traditional methods of educating specialists from developing countries have serious drawbacks. A third alternative is that educators from the developed countries participate locally in the education and practice of neurosurgery. The author reports his experience of living and working in Taiwan.

Fronto-orbito-sphenoidal fibrous dysplasia.

Eight patients with fronto-orbito-sphenoidal fibrous dysplasia, aged between 9 and 37 years, half of them male, were radically or nearly radically excised with immediate autogenous bone graft reconstruction. They had had frontal bulging and proptosis on the affected sides for 3 to 20 years. Four had decreased vision on the diseased side, and among them 1 had corneal ulceration due to proptosis and lower lid intropion. Optic nerve decompression was used with the other 3 patients who had narrowed optic canals. Cosmetic improvement was achieved after surgery. The vision of the normal and blind eyes was not changed after optic nerve decompression. The progression of visual loss stopped after surgery. One eye with decreased vision improved after optic nerve decompression.

Surgical treatment of spontaneous cerebellar hemorrhage.

UNLABELLED: Spontaneous cerebellar hemorrhage accounts for 5%-10% of intracerebral hemorrhage in most series. From June 1979 to June 1983 we had 26 surgical cases of spontaneous cerebellar hemorrhage. There were 15 men and 11 women. The typical history was sudden onset of severe headache, vomiting, dizziness, and inability to walk. Disturbance of consciousness was usually a late feature. Common signs were truncal ataxia, nystagmus, conjugate eyeball deviation, small miotic pupils with or without light reflex and abducens palsy. Surgical indications are (a) disturbance of consciousness, (b) signs of brainstem compression and (c) hematoma with transverse diameter greater than 3 cm. The overall surgical mortality was 34.6%. Twenty-two patients underwent suboccipital craniectomy to evacuate hematomas with or without ventriculostomy; mortality rate was 27%. Four patients underwent ventriculostomy only; mortality was 75%. Causes of death were (a) brainstem failure, six patients; (b) airway obstruction, one patient; (c) chest infection, one patient; (d) chronic renal failure, one patient. CONCLUSION: (a) suboccipital craniectomy to evacuate the hematoma is the most effective procedure where treatment is indicated; (b) the clinical recovery of the survivors show that 31% return to work, 38% are moderately disabled but take care of themselves, and 31% remain dependent on others; (c) deeply comatose patients may still benefit from early operation.

Transoral anterior decompression for treatment of unreducible atlantoaxial dislocations.

Three cases of nonreducible atlantoaxial dislocation are reported. Transoral anterior decompression followed by posterior fusion was done with good results in all three cases.

Intradural rupture of lumbar intervertebral disc.

Two cases of intradural disc rupture with cauda equina compression are reported. Myelography demonstrated complete block and at surgery intradural fragments of sequestrated disc material were found. The pathogenesis of this condition is reviewed and our recommendation for management is presented.

Hemifacial spasm: results of microvascular relocation.

Twenty patients with hemifacial spasm were treated between February 1980 and June 1981. All presented with typical disabling unilateral contractions of the face. Computerized Tomographic Scan and angiograms ruled out structural mass lesions. All patients underwent posterior fossa microsurgical relocation of a vessel from the root entry zone of the facial nerve. An offending arterial loop was found in each case. Nineteen patients are free of symptoms and the remaining one is improved. One patient has permanent loss of hearing and two developed mild facial weakness. There has been no recurrence in 18 months follow up. These results given further support to the theory that hemifacial spasm is an affliction of the seventh nerve in the cerebello-pontine angle, most commonly caused by vascular cross compression at the root entry zone. Surgical relocation of the offending vessel relieves the symptoms and there appears to be no recurrence. This procedure is not difficult and carries acceptable risk for the patient with this disabling condition.

Microangiographic study of experimental spinal cord injuries.

The pathology of spinal cord injury has been studied in 34 rabbits and 5 dogs with attention focused on the condition of the microvasculature during the evolution of neuronal and axonal degeneration and necrosis. The animals were killed and perfused arterially with colloidal barium from 10 min to 14 days after a controlled spinal injury. Microradiographs of the injured tissues were obtained and compared with corresponding histological sections. Microangiography at 7 to 14 days defines two zones in the injured spinal cord. Zone 1 is located in the posterocentral part of the cord. Capillaries in this region progressively lose their ability to conduct blood and perfusate over the first 4 hours. Degenerative changes in neurons are visible by 1 hour after injury. Necrosis of all elements including capillaries ensues. Zone 2 surrounds Zone 1. Microvascular patterns are normal in Zone 2 although neuronal and axonal degeneration is severe. Pericapillary hemorrhages which occur as early as 10 min after injury in Zone 1 and become progressively larger over the first 4 hours seldom are seen in Zone 2. The evidence indicates that at all times in the pathogenesis of spinal cord injury the microvasculature in Zone 2 is capable of perfusion. Degeneration of neural structures either precedes microvascular breakdown (Zone 1) or occurs in the absence of microvascular disruption (Zone 2). Recovery of damaged neurons and axons depends upon a preserved microcirculation.