Second thoracic sympathetic ganglionectomy in sympathetically maintained pain.

Twenty-four individuals with sympathetically maintained pain were treated by posterior paravertebral T2 sympathectomy following transient response to sympathetic nerve blockade. Eight surgical patients (33.4%) had causalgia, and 16 patients (66.4%) suffered with reflex sympathetic dystrophy. Overall, physical evidence of improvement was noted in 87% of surgical patients, with subjective improvement in 71%. Reflex sympathetic dystrophy patients fared better than those with causalgia. Complications were minor. The techniques employed appear safe and effective; a multidisciplinary approach with neurosurgery, physiatry, anesthesiology, psychology, and allied health services is recommended.

Informed consent: is it a myth?

The issue of informed consent at it relates to neurosurgical professional malpractice liability and litigation has been of concern for 20 years or more. The problem persists, and the subject has been addressed by providing patient education with full disclosure regarding neurosurgical procedures. In the process of imparting informed consent, the authors studied the effectiveness of specific neurosurgical health care teaching. One hundred six persons undergoing anterior cervical fusion or lumbar laminectomy were instructed by a neurosurgeon and clinical nurse specialist with a master's degree in neurosurgery. Written testing was performed in each case immediately after a formal teaching session before surgery. Questions were simple and covered only four general topics: 1) diagnosis and surgical techniques; 2) operative risks; 3) postoperative care; and 4) goals and benefits relating to surgery. The mean score on testing immediate retention of information revealed a 43.5% overall performance rate. When patients were tested approximately 6 weeks later, the score dropped to 38.4%. This was statistically significant (chi 2, P less than 0.05). The authors encourage the concept of patient education. The data in the current study, however, suggest that the reasonable and prudent neurosurgeon making a concerted effort at patient education, with the assistance of a professional educator, cannot necessarily expect accurate patient or family recall or comprehension. Fulfillment of the doctrine of informed consent by neurosurgeons may very well be mythical.

The management of paralytic spasticity.

The treatment of spasticity in severely paralyzed patients undergoing rehabilitation constitutes a significant neurosurgical challenge that requires comprehensive management. In this study, 118 patients were treated with invasive modalities when medical therapy failed. The results of percutaneous radiofrequency foraminal rhizotomy were initially successful in 95% of the 77 patients who underwent this procedure; the rate of minor complications was 5%. This procedure was satisfactorily supplemented with percutaneous radiofrequency sciatic neurectomy in 32 of these 77 patients. Four myelotomies were performed with complete success and no major complications in patients in whom percutaneous techniques had proven inadequate. In 35 instances of focal spasticity and incomplete paralysis, intramuscular neurolysis by phenol injection was used. The success rate was 89%. In 9 patients with persistent recurrent spasticity of the lower limb, open tenotomies and peripheral neurectomies were done. Success was complete and without complications. Multiple modalities must be available for the comprehensive management of patients with paralytic spasticity.

Rehabilitative neurosurgery.

The neurosurgical role in rehabilitation rehabilitation was studied. Over a 5-year period, 850 individuals were referred to a rehabilitation center after initial acute care. Surgery was indicated for 66 patients. There were 28 quadriplegic or paraplegic individuals with intractable spasticity. Percutaneous radiofrequency foramenal rhizotomies were found to be 98% effective in relieving posttraumatic spasticity. In 14 patients with cognitive impairment, intellectual improvement had reached a plateau level. These persons underwent computed tomography scanning and cisternography, revealing significant communicating hydrocephalus. After surgical shunt therapy, cognitive improvement was noted in 86%. Nineteen individuals were sent for rehabilitation following spine fracture or progressive quadriplegia; 17 were found to have persistent spinal instability requiring surgical stabilization by fusion. This was successful in all cases without complications. Two persons required decompressive spinal operations, resulting in neurological stabilization or improvement. Five patients developed pain, spasticity, ascending neurological deficit, or autonomic dysreflexia due to posttraumatic syrinx. These symptoms were stabilized or improved following syringosubarachnoid shunting. The authors submit that comprehensive neurosurgical reevaluation is desirable in patients received for rehabilitation. Periodic neurosurgical follow-up is recommended. The neurosurgeon's role is not limited to the acute process.

Spinal hemangiomas.

Three new cases of spinal cord compression due to vertebral hemangioma are reported. The clinical presentation, with spinal pain, radicular radiation, and paraparesis, is similar to that of primary lymphoma, metastatic tumor, and disc disease. If the characteristic plain film changes of vertical trabeculations and striations are present, the preoperative diagnosis is facilitated, but in the majority of cases these are not seen. In some instances, vertebral body or pedicle erosion is present. A myelographic epidural block will be seen on further study. Spinal arteriography can prove helpful. Surgical decompression results in marked neurological improvement if intervention takes place before the onset of complete paralysis. The authors recommend that the diagnosis of vertebral hemangioma be considered in the differential diagnosis of epidural spinal cord compression whenever considered in the differential diagnosis of epidural spinal cord compression whenever a primary malignant neoplasm cannot be identified.

Percutaneous radiofrequency foramenal rhizotomies.

Thirty quadriplegic and paraplegic patients with intractable spasticity underwent percutaneous radiofrequency foramenal rhizotomies. This produced improvement in 94% of the patients, with excellent results in 73%. The complication rate was 3%. The major disadvantage of the procedure was recurrent spasticity, which was dealt with by simple repetition of the procedure. Rehabilitative goals were facilitated; needless painful disability was avoided; a need for intense nursing was reduced; the prevention and treatment of decubitus ulcer formation was enhanced. The study suggests that this procedure is effective, inexpensive, and at low risk to the patient.

Transseptal transsphenoidal hypophysectomy.

The usual surgical approach to the sella turcica is via a labial sulcus incision over the nasal spine with continuation backward to the nasal septum and sphenoid sinus. In our series of 25 transsphenoidal hypophysectomies, a primary transseptal approach was used, avoiding the oral incision. The operating time was reduced, and the visualization was adequate. The morbidity associated with the labial sulcus incision was also avoided. The surgical approach and results are discussed.

Intracranial meningiomas of infancy, childhood and adolescence. Review of the literature and addition of 9 case reports.

The authors add 9 cases of pediatric meningiomas to 112 previously published cases and review clinical findings. Characteristic clinical and radiologic features are discussed in an attempt to identify settings where the diagnosis of intracranial meningioma should be considered in a child. Preoperative evaluation and outcome are also reviewed.

Self-contained tubular drill guard for anterior cervical fusion.

A self-contained tubular drill guard was adapted for use in performing anterior cervical discectomies and interbody fusions. The use of this instrument eliminates steps, provides absolute safety against drilling too deeply, allows for adjustment in individual cases, provides for easy inspection of the trephine hole, permits electing the cephalocaudal angle of the drill, and gives a measurement of the ultimate depth of the trephine hole. In 171 consecutive operations only one neurological complication occurred, and total morbidity related to cervical surgery was 6% (7% morbidity was associated with surgery at the donor site). The data suggest that the technical modification herein advocated reduces the surgical complication rate.

Pial microcirculation in subarachnoid hemorrhage.

Microsurgical and microscopic methods were employed in guinea pigs to expose, observe, and measure response characteristics of cerebral cortical pial microvessels and microcirculation to traumatic and nontraumatic experimental subarachnoid hemorrhage. Bleeding produced by vascular micropuncture was associated with a 44.3% arteriolar constriction. Topical application of homologous blood alone produced a 33.2% vasoconstriction. Observed microcirculatory flow characteristics subsequent to such microvascular changes were consistent with those known to be associated with cerebral cortical infarction. These changes could be prevented or reversed by topical application of the alpha adrenergic blocker, phenoxybenzamine. Topical pretreatment with the beta adrenergic blocker, propranolol, prevented blood-induced spasm, but did not reverse such spasm once it had been established. A chemo-mechanical mechanism is suggested as underlying the vasoconstriction association with rupture of pial microvessels. It is thought that consideration of such microvascular characteristics, in conjunction with those known to be associated with larger intracranial vessels, adds to current knowledge of the pathophysiology of subarachnoid hemorrhage and may be extrapolated to bear future clinical import.

Meckel's cave meningiomas with subarachnoid hemorrhage.

Two patients with Meckel's Cave meningiomas were initially hospitalized as a result of subarachnoid hemorrhage. Four-vessel angiography was necessary to exclude other causes of bleeding while demonstrating these lesions. Apoplectic presentation in both cases led to early diagnosis and successful surgical therapy. A review of the literature reveals subarachnoid hemorrhage to be a rarity in association with meningiomas. The two patients currently reported are believed to be the only examples on record of hemorrhagic meningiomas arising from the region of Meckel's Cave.

Cerebral angiographic changes associated with tuberous sclerosis.

Two patients with tuberous sclerosis were examined angiographically. In one, direct left carotid angiography showed a contralateral shift of the anterior cerebral artery and lateral displacement of the middle cerebral artery. On the lateral series, increase in the sweep of the anterior cerebral artery as well as stretching of the opercular branches of the middle cerebral artery were noted in the early arterial phase. In the later arterial phase, there was marked hypervascularity, with the contrast substance temporarily pooling in small, rounded collections. In the mid-arterial phase of the second case, pooling of the the contrast medium within the tumor and many small, berry-like outpunchings were noted. There was no evidence of early venous drainage in either case.