摘要:

&NA;The reported results of treatment of intramedullary spinal cord tumors (IMSCT) are difficult to interpret because of heterogeneous management strategies, small numbers of patients, and short periods of follow‐up. In 1985 we published the early results of operative treatment of 29 patients with IMSCT and were cautiously optimistic that aggressive operative management would have a salutary effect on long‐term outcome. In this report, the most recent clinical status of these 29 original patients is reviewed, along with that of 22 additional ones, to assess the intermediate and long‐term results of treatment of IMSCT in 51 patients who underwent microsurgical resection between 1981 and 1987. Of these 51 patients, 24 had ependymomas, 18 had astrocytomas, and the remainder had a variety of less common lesions. Thirty‐seven patients survive and have been followed for periods up to 72 months (mean 38 months). The neurological conditions of 21 patients are improved or have stabilized following operation. The conditions of 16 patients are worse postoperatively: 11 from operation and 5 from progression of disease. Eight patients are neurologically intact, 7 walk independently but abnormally, 9 ambulate with the aid of a cane or walker, and the remaining 13 are not ambulatory. Twelve of 18 patients with astrocytomas and 2 of 24 patients with ependymomas have died after a mean survival of 10 months from operation. Patients with ependymomas who had gross total resection have fared the best, with no deaths or recurrences, but no relationship could be discerned between the extent of resection and outcome in patients with astrocytomas. The author concludes that radical resection of IMSCT may be performed with initial stabilization or improvement of neurological function in the majority of patients. In patients with ependymomas the extent of resection correlated well with long‐term outcome. In patients with astrocytomas. however, there was no such relationship. All 7 patients with astrocytomas of Grades III and IV have died, as have 4 of 11 patients with astrocytomas of Grades I and II. (Neurosurgery25:855‐859, 1989)

ISSN:0148-396X    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

&NA;The clinical findings and the results of surgical treatment in 16 patients with spinal dermoid or epidermoid tumors are reported. In 9 patients the tumor capsule adhered so tightly to the nervous tissue that part of it was left in situ. In a follow‐up study ranging from 5 to 30 years with a mean of 14.2 years only 1 patient had a recurrence of the tumor and 10 patients resumed a normal working life. (Neurosurgery25:860‐864, 1989)

ISSN:0148-396X    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

&NA;Between June 1984 and April 1988, 41 patients with severe posttraumatic lesions of the cervical spine between the C2‐C3 and the C7‐T1 level seen consecutively were treated by an anterior cervical fusion and osteosynthetic stabilization according to Caspar. These patients were prospectively studied. Seven patients had a bilateral facet dislocation, 5 a unilateral facet dislocation, 9 an anterior subluxation, 9 an anterior compression fracture, 5 a hangman's fracture, and 6 a hyperextension injury at a lower cervical level. From a neurological point of view, there were 12 patients with an initial complete transverse lesion and 14 with an incomplete transverse lesion, and the remaining 15 patients did not have any deficit initially. Four patients died during the first 3 months after the operation. In 38 patients good anatomical position was obtained, generally by the intraoperative use of the vertebral distractor of Caspar. In all patients excellent immediate postoperative stability of the spine was obtained, although in 2 patients a second operation was necessary a few days after the first one. Postoperatively all patients were “immobilized” by a soft collar for 3 months. Four patients with an initial complete transverse lesion showed some neurological recovery in the postoperative period, and all patients with an incomplete transverse lesion improved. There were no postoperative neurological disturbances in the group of patients who were neurologically normal from the beginning. The mean postoperative hospitalization time was 13.6 days. These results were compared to the results from the literature, concerning other conservative and operative treatments for posttraumatic lesions of the cervical spine. (Neurosurgery25:865‐871, 1989)

ISSN:0148-396X    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

&NA;Thirty‐four patients with metastatic tumors of the spinal column exhibiting vertebral collapse and posterior element disease were treated by a single‐stage operation combining decompression of the vertebral body with posterior spinal instrumentation. Attention is drawn to the use of computed tomographic scanning in planning the operative approach. The indications for surgery were neurological deficit in 32 patients and pain in 2; 14 patients received preoperative radiotherapy. Of the 21 patients who were nonambulant preoperatively, 67% walked again, 21% regained sphincter control, and 68% had less pain. The surgical mortality was 12%; wound infection and dehiscence occurred in 15%. These results indicate that a single‐stage decompression and posterior stabilization may improve neurological function dramatically in patients with malignant cord compression. The operative morbidity and mortality is comparable to that of laminectomy. (Neurosurgery25:872‐876, 1989)

ISSN:0148-396X    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

&NA;Severe chronic low back pain was diagnosed in 236 patients by one physician and they were referred to the University of Miami Comprehensive Pain and Rehabilitation Center (UMCPRC) over a 5‐year period for an intensive 4‐week inpatient treatment program. Of these 143 (61%) were able to be contacted by telephone and given a structured interview designed for the study. The average time elapsed at follow‐up from referral for all patients was 22.5 months. Outcome was measured in the following terms: current levels of pain, percent decrease in pain, subsequent health care utilization, activities of daily living, and attitudes toward treatment. After completion of the interview, the McGill Pain Questionnaire and the Oswestry Low Back Pain Disability Questionnaire were sent to the patients. The patients fell into five groupings: Group 1—participants in the UMCPRC program (n = 39); Group 2—those whose participation was not approved by insurance (n = 30); Group 3—those who declined participation (n = 46); Group 4—participants in other programs (n = 14); Group 5—dropouts (n = 14). The five groups were not meaningfully different with regard to prereferral demographics. Interestingly, Group 1 patients exhibited significantly greater prereferral pain and unemployment levels. Despite this, at follow‐up significantly more Group 1 members were employed and they exhibited a greater percent decrease in pain as compared to the nonparticipant groups. Returned McGill and Oswestry Questionnaires mirrored these findings. Group 1 members also demonstrated significantly lower rates of subsequent health care utilization, i.e., physician visits, hospitalizations, and surgery than the nonparticipant groups. In conclusion, independent evaluation suggests that the type of program given at UMCPRC is effective for the treatment of chronic intractable low back pain. Future directions are briefly discussed. (Neurosurgery25:877‐883, 1989)

ISSN:0148-396X    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

&NA;We reviewed 9 cases of sacral tumors with presacral extension. These included 2 chordomas. 1 metastatic renal cell carcinoma, 2 schwannomas (1 malignant, 1 benign), 1 neurofibroma, 1 neurofibrosarcoma, 1 aneurysmal bone cyst, and an exceedingly rare meningioma. The sex of the patients was not significant. The age of the patients at diagnosis ranged from 13 to 68 years (mean, 47 years). Initial symptoms of low back and radiating leg pain were present in all but 1 patient. The duration of symptoms prior to diagnosis ranged from 1 month to 9 years (mean, 2.6 years). A delay in diagnosis of 2 years or more occurred in 6 of the 9 patients. Progressive perineal numbness and/or sphincter dysfunction were seen in 6 patients, and a palpable rectal mass was noted in 6 of 9 patients. The efficacy of various diagnostic tests is presented, as are the surgical options—needle biopsy and anterior and posterior approaches. Despite improved radiographic imaging techniques, these unusual tumors are often diagnosed at an advanced stage, and may masquerade as discogenic radiculopathy. Late diagnosis contributes to the difficulty of surgical extirpation. Anterior and posterior surgical approaches involving general, orthopedic, and urological surgeons may be required. (Neurosurgery25:884‐891, 1989)

ISSN:0148-396X    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

&NA;Segmental endothelial desquamation of the common carotid artery was produced in 30 rats using a balloon catheter technique which produces consistent proliferation of intimal smooth muscle cells from 5 to 20 days after injury. Immediately after endothelial injury, 15 animals were treated with periadventitial application of heparin contained in a continuous‐release drug‐delivery system using the polymer polyvinyl alcohol (PVA) and PVA alone applied in a similar fashion to 15 control rats. Animals were killed at 5, 10 and 20 days, respectively, after surgery by intracardiac perfusion‐fixation, and vessels were prepared for light microscopy, scanning electron microscopy, and immunohistochemistry with antibodies directed against actin. At all time periods, there was a significant reduction in intimal crosssectional area in heparin/PVA‐treated vessels compared to control vessels. Scanning electron microscopy showed complete absence of endothelial cells from the luminal surface in both control and treated arteries at all time periods without evidence of significant platelet aggregation. Immunohistochemistry demonstrated the presence of immunoreactive actin in the proliferating myointimal cells. Femoral venous prothrombin time and partial thromboplastin time were unchanged in heparin/PVA‐treated animals compared to controls at 1, 5, and 10 days. Continuous‐release polymer drug delivery can be used to apply heparin selectively to the adventitial surface of vessels and effect changes in the vessel wall over periods of up to 3 weeks. By this means, smooth muscle proliferation and subsequent vessel narrowing after endothelial injury were inhibited without systemic anticoagulation. This technique may be applicable to both clinical and research applications related to the pathophysiology of arterial injury. (Neurosurgery25:892‐898, 1989)

ISSN:0148-396X    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

&NA;Intraoperative monitoring with electroencephalography and the use of brain protection with steroids, phenytoin, mannitol, and pentobarbital or etomidate were evaluated in 15 patients undergoing operation for an aneurysm of the upper basilar artery. One patient harbored a basilar trunk aneurysm, 1 an aneurysm of the proximal posterior cerebral artery, 3 an aneurysm of the superior cerebellar artery, and 10 an aneurysm at the basilar tip. The size of the aneurysms varied between 5 and 30 mm. Subarachnoid hemorrhage was the symptom exhibited in 12, mass effect the symptom in 2, and 1 patient was asymptomatic but had an angiogram because of amaurosis. There were 9 patients with multiple aneurysms, 5 of whom had aneurysms of the bilateral anterior circulation. Four patients underwent operation early. In 2 patients, the basilar artery was the sole or main blood supply of the whole brain. All patients except the one with the basilar trunk aneurysm were operated on via a transsylvian approach. All patients received 500 to 800 mg of phenytoin and 10 to 20 mg of dexamethasone shortly before and during surgery, and mannitol (0.8 g/kg) 15 minutes before the induction of hypotension or temporary clipping. Three patients showed slowing of electrical activity over the right hemisphere as a result of retraction of the internal carotid artery; with repositioning of the retractor, this disappeared within 10 minutes. Electrocortical silence was induced in 8 patients; this was in anticipation of prolonged moderate hypotension in 2, short deep hypotension in 2, temporary clipping of major vessels—including the basilar artery—in 2, and a combination of deep hypotension combined with temporary clipping in 2. At present, etomidate is preferred over thiopental for inducing electrocortical silence because it has no cardiovascular depressant effects, even in massive doses. Three patients awoke with contralateral hemiparesis, 2 of whom had spontaneous changes in the electroencep halogram and 1 in whom electrocortical silence was present for 1 hour. In all 3 patients, the electroencephalogram had returned to normal by the end of the operation, and the hemiparesis had completely resolved within 4 hours. One patient, in whom the basilar artery itself had ruptured and had to be occluded permanently, died. One patient, whose status was Grade 4 when operation was performed on Day 25, remained severely disabled. All other patients made a good recovery. The electroencephalogram was helpful in 10 cases (67%), and it allowed the surgeon to operate without stress in an unhurried manner and, when combined with pharmaceutical brain protection—even in the presence of deep hypotension—to perform temporary clipping. (Neurosurgery25:899‐903, 1989)

ISSN:0148-396X    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

&NA;Despite modern neurosurgical technology and neuroanesthetic care, treatment of aneurysms of the distal basilar artery remains fraught with complications. Between 1982 and 1988, 126 patients with aneurysms of the distal basilar artery who had been treated by 2 surgeons were retrospectively analyzed to determine the causes of morbidity and mortality from this disease and its treatment. Ten patients (8%) died, and 14 patients (11%) suffered permanent neurological disability after treatment. The causes of failed management could be grouped into the following categories: 1) direct effects of hemorrhage; 2) errors in surgical timing; 3) conceptual errors; 4) technical errors; 5) morbidity from delayed cerebral ischemia; and 6) complications of hypertensive/hypervolemic therapy for symptomatic vasospasm; a small group of patients who died despite having received what we consider excellent management were grouped under a seventh category, “bad luck.” Frequently, patients who did poorly suffered from multiple complications, each of which contributed to their overall morbidity. It is our hope that increased awareness of these potential pitfalls and the further evolution of intravascular technique in selected cases will, in time, improve the outlook for patients suffering from these dangerous lesions. (Neurosurgery25:904‐916, 1989)

ISSN:0148-396X    

出版商:OVID    

年代:1989

数据来源: OVID

摘要:

&NA;In vitro studies of the canine basilar artery have demonstrated that calmodulin antagonism can effectively inhibit cerebral arterial smooth muscle contractility. The prophylactic and therapeutic effectiveness of a potent calmodulin antagonist, the phenothiazine compound trifluoperazine (TFP), was investigated in vivo over a wide range of doses in the well‐documented “double‐subarachnoid hemorrhage” canine model of cerebral vasospasm. The compound is perhaps more well‐known under its trade name, Stelazine, as a classic antipsychotic drug. The drug demonstrated no therapeutic relief of preexisting chronic cerebral vasospasm at any time during 2 days of systemic administration at any practical dose. At doses far in excess of the normally accepted therapeutic range in humans, a prophylactic regimen reduced the severity of chronic cerebral vasospasm after subarachnoid hemorrhage by approximately 35% compared to untreated dogs. (Neurosurgery25:917‐922, 1989)

ISSN:0148-396X    

出版商:OVID    

年代:1989

数据来源: OVID