The role of spinal fusion in surgery for lumbar spinal stenosis: a review.

The authors undertook a review of the literature and analysis of the local surgical experience for lumbar stenosis to define the role of simultaneous arthrodesis in the treatment of patients undergoing decompression for spinal stenosis. The restrained use of spinal fusion is recommended in spinal stenosis surgery because of the coexisting medical problems in the elderly patient population and the higher associated complication rate with spinal fusion and instrumentation. A spinal fusion is recommended when decompression is performed in an area of segmental instability as manifested by gross movement on flexion--extension radiographs; when the decompression coincides with an area of degenerative instability, as with scoliosis or spondylolisthesis; or when the decompression creates an iatrogenic instability by the disruption of the posterior elements.

A clinical and neuropathologic study of silk suture as an embolic agent for brain arteriovenous malformations.

Purpose: To evaluate the safety and efficacy of silk suture as an agent for preoperative embolization of cerebral arteriovenous malformations.

Methods: Clinical and histopathologic results were analyzed in six patients who underwent embolization of cerebral arteriovenous malformations using silk suture in combination with other agents.

Results: Three of the patients treated with silk hemorrhaged after embolization, and two of these patients died.

Long-term evaluation of decompressive surgery for degenerative lumbar stenosis.

One-hundred patients who had undergone decompressive surgery for lumbar stenosis between 1980 and 1985 were evaluated as to their long-term outcome. Four patients with postfusion stenosis were included. A 5-year follow-up period was achieved in 88 patients.

Reliability of left and right indicators in CT scanning of the head. Case report.

A case is described in which incorrect preliminary programming of a computerized tomography (CT) machine caused transposition of the left- and right-side indicators in a CT scan, which led to craniotomy on the normal side. The possible mechanism for this is incorrect pre-scan programming of the CT scanner with respect to patient positioning in the scanner gantry. This error, although unlikely, is still possible with the present generation of CT scanners.

Positional vertigo and the cerebellar vermis.

A patient with lower and posterior vermis hematoma presented with truncal ataxia; paroxysmal, positional, downbeating nystagmus; and saccade dysmetria. Drainage of the hematoma resulted in complete resolution of all signs and symptoms.

Childhood medulloblastoma presenting with hemorrhage.

Cerebellar hemorrhage is rare in childhood, and is usually the result of trauma or a ruptured arteriovenous malformation. We report acute subarachnoid hemorrhage as the presenting manifestation of medulloblastoma and review the atypical presentation and causes of cerebellar hemorrhage in infants and children.

Cerebral arteriovenous malformations. Indications for and results of surgery, and the role of intravascular techniques.

To address the problems of surgical risk versus natural risk associated with cerebral arteriovenous malformations (AVM's), and the role of the intravascular operative approach, the authors have assessed a 20-year experience with 450 patients. Results of direct surgery in 90 patients indicate that for the smaller AVM's (Grades I and II), mortality and morbidity rates are lower than a reasonably projected natural risk. Hence, these patients are candidates for surgery in most instances.

Cervical myelopathy due to atlantoaxial and subaxial subluxation in rheumatoid arthritis.

Four patients aged 41 to 73 years, who had had rheumatoid arthritis for eight to 25 years, had signs and symptoms of cervical myelopathy and radiculopathy due to either atlantoaxial dislocation with herniation of the odontoid through the foramen magnum, or subluxation of the middle to lower cervical vertebrae. Spastic paraparesis or quadriparesis, severe nuchal immobility and pain, and flaccid paresis of the upper limbs necessitated anterior medullary decompression and posterior cervical fusion. Postmortem examination disclosed old ischemic necrosis, atrophy, and gliosis in the low medulla and cervical cord.

Dissecting aneurysm of intracranial vertebral artery: case report and review of literature.

A spontaneous dissecting aneurysm of the intracranial portion of the dominant right vertebral artery presented as massive subarachnoid hemorrhage, excruciating headache, and respiratory arrest in a 57-year-old white man with a history of systemic hypertension. He died on the 3rd day. Postmortem examination revealed a dissecting hemorrhage extending for 2.

Estimate of the incidence and importance of circulatory breakthrough in the surgery of cerebral arteriovenous malformations.

Severe hemorrhagic brain swelling has been described occasionally in patients with cerebral AVMs after surgical interruption for feeding arteries, surgical excision, and embolization. The proposed mechanism is an abrupt increase in perfusion pressure in the vasculature of the normal adjacent brain which has lost its capacity to autoregulate. The term circulatory breakthrough has been adopted to describe this.

Subarachnoid hemorrhage secondary to an aneurysm of the ascending pharyngeal artery: case report.

The authors report a patient presenting with subarachnoid hemorrhage (SAH) secondary to one of two saccular aneurysms arising from the dural branches of the ascending pharyngeal artery. The aneurysms were obliterated by surgery without complications. Satisfactory visualization of the aneurysms required selective external carotid angiography with magnification and subtraction.

Embolization of segments of the circle of Willis and adjacent branches for management of certain inoperable cerebral arteriovenous malformations.

Most large cerebral arteriovenous malformations (AVM's) in the territories of the penetrating arteries arising from the circle of Willis, including the proximal anterior, middle, and posterior cerebral arteries, have been considered untreatable. However, the pattern of collateral circulation which accompanies these lesions presents the possibility of completely occluding certain segments of the circle of Willis and adjacent major branches without producing infarction distally in the cerebral hemisphere or in the critical areas occupied by the AVM itself. The ensuing reduction of arterial pressure within the AVM may reduce the likelihood of hemorrhage or progressive enlargement.

Removal of occipital arteriovenous malformations with sparing of visual fields.

Two patients with occipital lobe arteriovenous malformation (AVM) underwent two-stage resection of their lesions. The intervals between operations were eight and 12 days. Prior to surgery, the patients had normal neuro-ophthalmologic examination results and both experienced a reversible homonymous hemianopsia after the initial, partial resection of the AVM.

Cavernous hemangioma of optic chiasm, optic nerves and right optic tract. Case report and review of literature.

Diminishing right ocular visual acuity for three weeks in a 30 year old man was confirmed by examination. Bilateral scotomata and bitemporal hemiachromatopsia indicated a chiasmal lesion; reduced visual acuity and Marcus Gunn pupil of the right eye and left relative temporal hemianopia indicated asymmetric involvement. Erythrocytes in the CSF verified a suspected subarachnoid bleed; contrast-enhanced CAT scan demonstrated a suprasellar mass.

Anatomical grading of supratentorial arteriovenous malformations for determining operability.

After the study of over 300 angiograms of supratentorial cerebral arteriovenous malformations (AVM's), the authors have formulated an anatomical grading scheme of I to IV to correspond to the degrees of surgical difficulty for total obliteration. The grading is based upon the number of directly participating arteries for which there is a standardized nomenclature. Occasionally, allowance for clinical grading, in addition to this anatomical grading, must be made.

Observations on the electrocardiographic changes associated with subarachnoid hemorrhage with special reference to their genesis.

A 36 year old man presented with bizarre behavior and had abnormal electrocardiograms on two occasions. Because of ST-T wave changes, he was treated both times for a possible subendocardial infarction. A more complete evaluation during the second admission revealed a basilar artery aneurysm with subarachnoid hemorrhage as the cause of the central nervous system symptoms.

Selective sacral rootlet rhizotomy for hypertonic neurogenic bladder.

The authors describe a highly selective transsacral microsurgical procedure for sacral nerve rootlet interruption in five patients with hypertonic neurogenic bladder. Magnification and systematic stimulation of sacral roots provided accurate identification of motor fibers supplying bladder detrusor muscle and differentiation of efferent components to the legs and anal sphincter. Although the technique prevented incontinence and adverse effects of nerve section on rectal and lower extremity function improvement in voiding patterns and diminution of urinary sepsis was of brief duration in three of the five patients.

Surgical embolization of cerebral arteriovenous malformations through internal carotid and vertebral arteries. Long-term results.

The authors describe the clinical results of surgical embolization in 55 patients with large cerebral arteriovenous malformations. Follow-up intervals ranged from 2 months to 14 years, averaging 4 1/2 years. The authors believe the procedure is safe in properly selected patients and is useful as a preliminary to direct surgical excision.

Computerized transaxial x-ray tomography of the human body.

The ACTA-Scanner has virtually unlimited potential in the evalution of any part of the body. The usefulness of the technique has already been shown in the appraisal of pathologies of the brain and cerebrospinal fluid cavities. The orbits and the eyeballs, the facial sinuses, and skull base lesions have also been elucidated.