Surgical exposure of the brachial plexus.

A method of exposure of the brachial plexus is presented. Resection of the clavicle is emphasized in repairing large defects in the plexus to obtain primary anastomosis.

A 32-year experience with the surgical treatment of selected brachial plexus lesions with emphasis on its reconstruction.

Twenty-five patients with brachial plexus injury were treated by anastomosis, neurolysis, and calvicular decompression. The patients treated by anastomosis are described in detail because evidence of regrowth of axons across the anastomosis can be documented, whereas the effects of neurolysis are difficult to judge. The techniques of brachial plexus reconstruction are illustrated. Clinical improvement occurred in 93% of patients treated with anastomosis, 89% of those treated with neurolysis, and 100% of those treated with decompression. Electromyographic studies provided valuable information in assessment before and after surgery. The benefits of surgical therapy of brachial plexus injuries outweigh the risks in carefully selected patients.

Optic glioma. Long-term follow-up of 85 histopathologically verified cases.

Eighty-five cases of histologically verified gliomas of the optic nerve or chiasm were studied retrospectively. Patient survival was analyzed according to location of tumor, treatment received, presence of neurofibromatosis, and degree of histologic anaplasia. Thirty-three patients had optic nerve tumors, and 52 had tumors involving the chiasm. Follow-up ranged from 6 days to 43.7 years. Of the 33 patients with optic nerve tumors, 28 (85%) survived a mean duration of 17 years, and survival was significantly associated with completeness of surgical excision. Twenty-three of the 52 patients (44%) with chiasmal tumors survived a mean duration of 19 years. Survival among patients with chiasmal tumors was unrelated to therapy received and was affected adversely by concomitant involvement of adjacent brain structures. The presence of neurofibromatosis conferred a protective benefit to patients with chiasmal tumors. No other significant factors could be statistically identified to influence the prognosis of patients with optic gliomas.

Incidence of spinal column deformity after multilevel laminectomy in children and adults.

Fifty-eight patients, all less than 25 years of age, underwent multilevel laminectomy for conditions that in themselves do not usually cause spinal deformity. Spinal deformity developed in 46% (12 of 26) of the patients who were less than 15 years of age, but in only 6% (two of 32) of the patients aged 15 to 24 years. Spinal deformity developed in all (100%) patients who had cervical laminectomy, in 36% of those who had thoracic laminectomy, and in none (0%) of those who had lumbar laminectomy. There was no correlation between the occurrence of deformity and sex, number of laminae removed, neurological conditions after laminectomy, or length of time after surgery.

Pathogenesis and prophylaxis of postlaminectomy deformity of the spine after multiple level laminectomy: difference between children and adults.

The pathogenesis of postlaminectomy spinal deformity and instability in children was evaluated by reviewing appropriate roentgenographic findings. First, we reviewed spine roentgenograms of patients below 40 years of age who underwent spinal fusion for deformity and instability of the spine developing after a multiple level laminectomy. Two types of deformity were recognized on the roentgenograms: increased mobility between the vertebral bodies and wedging deformity of the ventral aspect of the vertebral bodies. Second, we did a follow-up study of another group of patients who had undergone laminectomy. We found the same two types of deformity in children, but not in adult patients. The incidence of deformity was higher after laminectomies of the cervical or cervicothoracic region than after lumbar laminectomies. Our data suggest that postlaminectomy spinal deformity can develop in children without irradiation or facet injury. The deformity is due to a wedging change in the cartilaginous portion of the vertebral body and to the viscoelasticity of ligaments in children. When treatment of this complication becomes necessary, anterior fusion may be effective in arresting progression. Prophylactic measures against the development of deformity are discussed. Our hypothesis concerning the mechanism of development of this complication supports the rationale of osteoplastic laminar resection and reconstruction instead of laminectomy, particularly in the management of children.

Randomized comparisons of radiotherapy and nitrosoureas for the treatment of malignant glioma after surgery.

Within three weeks of definitive surgical intervention, 467 patients with histologically proved malignant glioma were randomized to receive one of four treatment regimens: semustine (MeCCNU), radiotherapy, carmustine (BCNU) plus radiotherapy, or semustine plus radiotherapy. We analyzed the data for the total randomized population and for the 358 patients in whom the initial protocol specifications were met (the valid study group). Observed toxicity included acceptable skin reactions secondary to radiotherapy and reversible leukopenia and thrombocytopenia due to chemotherapy. Radiotherapy used alone or in combination with a nitrosourea significantly improved survival in comparison with semustine alone. The group receiving carmustine plus radiotherapy had the best survival, but the difference in survival between the groups receiving carmustine plus radiotherapy and semustine plus radiotherapy was not statistically significant. The combination of carmustine plus radiotherapy produced a modest benefit in long-term (18-month) survival as compared with radiotherapy alone, although the difference between survival curves was not significiant at the 0.05 level. This study suggests that it is best to use radiotherapy in the post-surgical treatment of malignant glioma and to continue the search for an effective chemotherapeutic regimen to use in addition to radiotherapy.

Uveitis and cerebral reticulum-cell sarcoma (large-cell lymphoma). Case report.

A patient with a peculiarly refractoy uveitis and vitritis was later found to have an infiltrative mass lesion of the posterior portion of the corpus callosum. The histopathological diagnosis of reticulum-cell sarcoma (large-cell lymphoma) was made after study of vitreous tissue obtained by pars plana vitrectomy of the right eye. Intraocular involvement with cerebral reticulum-cell sarcoma has been reported previously.

Foramen magnum tumors. Analysis of 57 cases of benign extramedullary tumors.

This study involved 57 patients with benign extramedullary tumors of the foramen magnum (19 neurinomas, 37 meningiomas, and one teratoma), who were operated on between 1957 and 1976. The 37 meningiomas represented 3.2% of 1139 meningiomas of the neuraxis. The initial neurological examinations of about half of these patients were unremarkable. The clinical presentation of tumors of the foramen magnum frequently mimics multiple sclerosis, cervical spondylosis, intramedullary tumor, syrinx, carpal tunnel syndrome, and even normal-pressure hydrocephalus. All operations were performed through a posterior approach, and two surgical deaths (3.5%) were recorded. No surgery for recurring of tumor was recorded. The follow-up review of 56 patients (98.2%) showed good functional results if the tumor was detected before severe neurological deficits occurred. The possible mechanism of the sensory symptoms and muscle atrophy of the hands is discussed, and the electromyographic findings are reviewed.

Brachial plexus injuries.

Brachial plexus injuries are uncommon. They are, however, complicated lesions because of the concomitant injury to adjacent structures and the imposing anatomy of the brachial plexus. Physicians who will be consulted in the management of such injuries should periodically consider the principles of management. Diagnosis of these injuries is based on clinical examination, myelography, axon reflex testing, and electrophysiologic studies. The lesion may be open or closed and supraclavicular or infraclavicular. It may be in continuity or there may be nerve disruption or root avulsion from the spinal cord. The anatomic relationships of the brachial plexus are reviewed, the pathophysiology of direct trauma, secondary trauma, and iatrogenic trauma is discussed, and the treatment of the various types of traumatic brachial palsy is surveyed.

Evaluation of BCNU and/or radiotherapy in the treatment of anaplastic gliomas. A cooperative clinical trial.

A controlled, prospective, randomized study evaluated the use of 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) and/or radiotherapy in the treatment of patients who were operated on and had histological confirmation of anaplastic glioma. A total of 303 patients were randomized into this study, of whom 222 (73%) were within the Valid Study Group (VSG), having met the protocol criteria of neuropathology, corticosteroid control, and therapeutic approach. Patients were divided into four random groups, and received BCNU (80 mg/sq m/day on 3 successive days every 6 to 8 weeks), and/or radiotherapy (5000 to 6000 rads to the whole brain through bilateral opposing ports), or best conventional care but no chemotherapy or radiotherapy. Analysis was performed on all patients who received any amount of therapy (VSG) and on the Adequately Treated Group (ATG), who had received 5000 or more rads radiotherapy, two or more courses of chemotherapy, and had a minimum survival of 8 or more weeks (the interval that would have been required to have received either the radiotherapy or chemotherapy). Median survival of patients in the VSG was, best conventional care: 14 weeks (ATG: 17.0 weeks); BCNU: 18.5 weeks (ATG: 25.0 weeks); radiotherapy: 35 weeks (ATG: 37.5 weeks); and BCNU plus radiotherapy: 34.5 weeks (ATG: 40.5 weeks). All therapeutic modalities showed some statistical superiority compared to best conventional care. There was no significant difference between the four groups in relation to age distribution, sex, location of tumor, diagnosis, tumor characteristics, signs or symptoms, or the amount of corticosteroid used. An analysis of prognostic factors indicates that the initial performance status (Karnofsky rating), age, the use of only a surgical biopsy, parietal location, the presence of seizures, or the involvement of cranial nerves II, III, IV, and VI are all of significance. Toxicity included acceptable, reversible thrombocytopenia and leukopenia.

Visual prognosis of optic nerve sheath meningiomas producing shunt vessels on the optic disk.

Nine patients--seven women and two men--had meningiomas of the optic nerve sheath. The defect was bilateral in two, in the right eye in six, and in the left eye in one. Most had edema of the disk, and all had progressive loww of vision in the affected eye owing to optic nerve atrophy. In 10 of the 11 affected eyes, opticocilliary shunt veins developed on the optic disk. Exophthalmos was mild and did not measure more than 3 mm in any patient. Ocular movement was mildly impaired in three patients. Indentation and flattening of the posterior pole of the eye were documented in five eyes. Nine of the 11 eyes progressed to blindness; 1 was worse after operation, and the outcome of the 11th is unknown because the patient was lost to follow-up. Surgical treatment has not been effective in these cases or in those reported in the literature.

Visual prognosis of optic nerve sheath meningiomas producing shunt vessels on the optic disk: the Hoyt-Spencer syndrome.

Nine patients, including seven women and two men, had meningiomas of the optic nerve sheath. The defect was bilateral in two, in the right eye in six, and in the left eye in one. Most had edema of the disk, and all had progressive loss of vision to blindness in the affected eye owing to optic nerve atrophy. In 10 of the 11 affected eyes, opticociliary shunt veins developed on the optic disk. Exophthalmos was mild and not more than 3 mm in any patient. Ocular movement was mildly impaired in three patients. Indentation and flattening of the posterior pole of the eye was documented in five eyes. Nine of the eleven eyes went on to blindness; one was worse after operation, and the eleventh was lost to follow-up. Surgical treatment has not been effective in these cases or in those reported in the literature.

Tension pneumocephalus after insertion of ventriculoperitoneal shunt for aqueductal stenosis.

A case of tension pneumocephalus after the insertion of a ventriculoperitoneal shunt for aqueductal stenosis is reported. The possible mechanisms producing this complication are discussed.

Chronic arterial insufficiency of the upper extremity.

When claudication or distal ischemia is significant, the treatment of choice for intrinsic arterial insufficiency of the upper extremity caused by atherosclerotic occlusive disease of the subclavian, axillary, or brachial artery with patent distal circulation is direct arterial surgery. Both endarterectomy and bypass procedures are utilized. In the 20 years from 1947 to 1967, 15 patients were operated on for such lesions and adequate circulation was restored in 12 patients treated by the direct method. Nine patients available for 1-year follow-up were cured of their symptoms; of the remaining three patients, one had amputation of an arm and two had sympathectomy with improvement. No hospital death occurred and morbidity was minimal. Although the diagnosis can be established on clinical grounds, arteriography is essential to ascertain the surgical procedure needed. Peripheral diseases involving the small arteries are clinically a more common cause of arterial insufficiency in the upper extremity; progress is slow and complications are infrequent. When ischemic complications exist, direct arterial surgery is not feasible and cervicodorsal sympathectomy is the usual form of treatment. Of 76 patients operated on for such disease, 74 underwent sympathetic neurectomy. The results were excellent, good, or satisfactory in 50 (78%) of the 64 traced patients. The remaining 14 patients had persistent or recurrent symptoms after operation. Removal of the stellate ganglion in addition to the second ganglion yielded better results and is indicated in recurrent or more cases.

Clinical manifestations of aqueductal stenosis in adults.

The authors review 17 cases of aqueductal stenosis in adults and describe five modes of clinical presentation. The average duration of symptoms was 6 years. Dementia was infrequent. Skull x-ray films frequently demonstrated some degree of cranial enlargement and signs of chronic increased intracranial pressure. Characteristic alterations of the sella included elongation of the anterior wall and flattening, erosion, and anterior displacement of the dorsum. Aqueductal configurations as defined by ventriculography and pneumoencephalography in all cases, and the angiographic findings in seven cases are described. Most of the patients improved substantially after shunt insertion. The clinical findings suggested that aqueductal narrowing and associated hydrocephalus had been present in most of these patients since early life.

Meningiomas of Meckel's cave.

A retrospective review of 12 cases of meningioma of Meckel's cave involving the Gasserian ganglion or the trigeminal posterior root (or both) seen at the Mayo Clinic during a 20-year period suggested three clearly defined clinical groups. One group (the largest) had typical trigeminal neuralgia and an excellent prognosis after the removal of the easily detachable mass that was impinging on the ganglion. A second group, with meningiomas en plaque embedded in the ganglion, had a history of atypical trigeminal face pain without neurological deficit, but the prognosis for pain relief was not as good as in the previous group. A third group had a history of face dysesthesias and pain, objective trigeminal sensory loss, and multiple cranial nerve deficit; these patients had meningiomas with histological signs of mitotic activity and a poor prognosis, with return of intractable pain and recurrence of the tumor.