Randomized trial demonstrates that extended-release epidural morphine may provide safe pain control for lumbar surgery patients.

Background: Safe and effective postoperative pain control remains an issue in complex spine surgery. Spinal narcotics have been used for decades but have not become commonplace because of safety or re-dosing concerns. An extended release epidural morphine (EREM) preparation has been used successfully in obstetric, abdominal, thoracic, and extremity surgery done with epidural anesthesia.

Lumbar sagittal contour after posterior interbody fusion: threaded devices alone versus vertical cages plus posterior instrumentation.

Study Design: An observational radiographic study examining lumbar sagittal contour of patients undergoing posterior interbody arthrodesis.

Objectives: To compare operative alterations of lumbar sagittal contour after posterior interbody fusion using threaded interbody devices alone versus vertical cages combined with posterior compression instrumentation.

Summary Of Background Data: Technique-related alterations of lumbar sagittal contour during interbody arthrodesis have received little attention in the spinal literature.

Measurement of thoracic and lumbar fracture kyphosis: evaluation of intraobserver, interobserver, and technique variability.

Study Design: Statistical analysis of various measurement techniques for thoracolumbar burst fracture kyphosis on lateral radiograph.

Objective: To determine the most reliable measurement technique.

Summary Of Background Data: The treatment of thoracic and lumbar burst fractures involves many factors, including the degree of resultant kyphosis.

Segmental stability and compressive strength of posterior lumbar interbody fusion implants.

Study Design: Human cadaveric study on initial segmental stability and compressive strength of posterior lumbar interbody fusion implants.

Objectives: To compare the initial segmental stability and compressive strength of a posterior lumbar interbody fusion construct using a new cortical bone spacer machined from allograft to that of titanium threaded and nonthreaded posterior lumbar interbody fusion cages, tested as stand-alone and with supplemental pedicle screw fixation.

Summary Of Background Data: Cages were introduced to overcome the limitations of conventional allografts.

A critical appraisal of the reporting of the National Acute Spinal Cord Injury Studies (II and III) of methylprednisolone in acute spinal cord injury.

From the beginning, the reporting of the results of National Acute Spinal Cord Injury Studies (NASCIS) II and III has been incomplete, leaving clinicians in the spinal cord injury (SCI) community to use or avoid using methylprednisolone in acute SCI on the basis of faith rather than a publicly developed scientific consensus. NASCIS II was initially reported by National Institutes of Health announcements, National Institutes of Health facsimiles to emergency room physicians, and the news media. The subsequent report in the New England Journal of Medicine implied that there was a positive result in the primary efficacy analysis for the entire 487 patient sample.

Spinal epidural abscess: contemporary trends in etiology, evaluation, and management.

Background: Despite advances in neuroimaging and neurosurgical treatment, spinal epidural abscess remains a challenging problem; early diagnosis is often difficult and treatment is delayed. Optimal management is unclear, and morbidity and mortality are significant. To define contemporary trends in etiology and management, and establish diagnostic and therapeutic guidelines, we reviewed our 10-year experience with spinal epidural abscess.

The "dural tail sign": not always a meningioma.

Periorbital masses are often referred to oculoplastic surgeons. We report a 20-year-old patient presenting with a tender supertemporal mass that on gadolinium-enhanced magnetic resonance imaging (MRI) demonstrated a prominent dural enhancement adjacent to the mass, the so-called "dural tail sign." This sign has been reported to be highly specific for a meningioma; however recent literature challenges this view.

Trends and complications in cervical spine surgery: 1989-1993.

In an effort to determine trends in surgery of cervical spine disorders and the incidence of complications resulting from this treatment, a mechanism was established for the collection and analysis of multicenter data on an every-5-year basis. This data collection technique allowed the tracking of trends in the treatment for specific diagnoses and determination of complication rates for individual procedures. We present the results occurring in 4,589 patients operated on by 35 surgeons per year between 1989 and 1993.

Intracranial metastatic adenocarcinoma of the prostate presenting as visual disturbance.

We report two cases of intracranial metastatic adenocarcinoma of the prostate that presented with visual disturbance. The two patients had no prior history of prostate cancer and both underwent invasive neurosurgical procedures. Progressive neurological decline mandated craniotomy in one patient and the other patient underwent transphenoidal surgery for biopsy.

Pneumosinus dilatans: a sign of intracranial meningioma.

Background: Pneumosinus dilatans affecting the sphenoid and posterior ethmoid sinuses has been reported in association with spheno-orbital meningiomas and is believed by some authors be a sign of an adjacent meningioma.

Methods: We report the case of a 57-year-old man who developed progressive neurologic signs and symptoms consistent with a frontal lobe lesion. Neuroimaging studies revealed a large partially cystic mass at the base of the anterior cranial fossa that appeared to be invading the left frontal lobe and that was associated with pneumosinus dilatans of the adjacent left frontal sinus.

Clinical applications of pharmacologic therapies for spinal cord injury.

We review the evidence supporting the role of glucocorticosteroids, trilazad, and GM1 ganglioside in spinal cord injury and provide our critique of the published studies, along with our recommendations for pharmacologic therapy for this complex and difficult problem.

One-stage anterior cervical decompression and posterior stabilization. A study of one hundred patients with a minimum of two years of follow-up.

One hundred patients were managed with one-stage anterior decompression and posterior stabilization of the cervical spine. The underlying indication for the operation was cervical trauma in thirty-one patients; a neoplasm with a pathological fracture or an incomplete neurological deficit in fifty-five; and a miscellaneous condition, such as infection, rheumatoid arthritis, or cervical spondylotic myelopathy, in fourteen. The duration of follow-up ranged from twenty-four to 108 months (mean, thirty-two months) for the living patients.

Complications of cervical discography: analysis of 4400 diagnostic disc injections.

Despite extensive experience with diagnostic cervical disc injection, the role of this procedure in the evaluation of patients with degenerative disc disease and severe neck pain remains controversial. Beyond the debate regarding its efficacy in identifying the site of cervical symptomatology and directing appropriate intervention are the potential morbidity and mortality associated with this diagnostic procedure. Discitis, subdural empyema, spinal cord injury, vascular injury, and prevertebral abscess have all been reported as complications of diagnostic cervical disc injection.

Reversibility of white matter changes and dementia after treatment of dural fistulas.

We describe two patients with dural fistulas who presented with dementia and diffuse white matter signal changes on MR that significantly improved after surgery. One patient had preoperative embolization.

Differentiating lymphocytic adenohypophysitis from pituitary adenoma in the peripartum patient.

Lymphocytic adenohypophysitis (LAH) is an autoimmune disorder of the pituitary gland with a predilection for the peripartum period and often mimics a pituitary adenoma. We sought to define the clinical, endocrinologic and radiographic characteristics differentiating peripartum LAH from pituitary adenoma to enable the use of noninvasive diagnosis and appropriate therapy. From published reports and our own case, the clinical histories and laboratory and radiographic studies of 45 patients fulfilling the diagnosis of peripartum LAH were reviewed.

Primary care for women. Comprehensive assessment of the neurologic system.

This article reviews the essential neuroanatomy and neurophysiology, and summarizes the components of the health history, physical exam, and laboratory tests required for an assessment of the neurologic system within the primary care setting. Brief case studies illustrate the wide range of symptoms associated with neurologic disorders in women and the manner in which the pattern of symptoms can be used to locate the site of pathology and indicate the need for referral and follow-up.

Intraventricular rupture of a purulent brain abscess: case report.

The mortality of patients with brain abscesses has decreased significantly from 38% in the 1950s to 25% in the 1980s (P = 0.003, Fisher's exact test by decade of report; asymptotic P values based on chi 2 distribution with 3 degrees of freedom, 28 series, 2825 total patients). This decrease in mortality has been attributed to improved diagnostic imaging, the evolution of neurosurgical techniques and understanding of intracranial pressure pathophysiology, greater critical care understanding, and newer antibiotics.

Spinal cord injury. Role of steroid therapy.

Study Design: The authors review the evidence supporting the role of glucocorticosteroids in spinal cord injury, critique published studies, and provide recommendations for steroid use in this complex and difficult problem.

Objectives: The authors detail the evolution of the use of glucocorticosteroids for acute spinal cord injury and objectively assess the results of NASCIS I and II.

Summary Of Background Data: Glucocorticosteroids were first used in patients with acute spinal cord injury in the 1960s.

Rheumatoid arthritis. Neuroanatomy, compression, and grading of deficits.

Study Design: The authors summarize published data regarding cervical spine involvement in rheumatoid arthritis, define the neurologic manifestations, and provide recommendations for management of these complex and difficult problems.

Objectives: The authors attempted to accurately define the neurologic lesions resulting from rheumatoid involvement of the cervical spine despite the complexity of the neuroanatomy of the cervicomedullary region and the diversity of pathology.

Summary Of Background Data: Despite the long-standing recognition of cervical spine involvement in rheumatoid arthritis, appreciation of the different neurologic manifestations of this disease has been lacking or misunderstood.

Posterior cervical laminoforaminotomy for radiculopathy: review of 172 cases.

Laminoforaminotomy performed with the patient in the sitting position with our improved techniques represents an effective treatment for cervical radiculopathy. We present the results of laminoforaminotomies performed in 172 patients with cervical radiculopathy during a 7-year period. The posterior approach in the surgical management of cervical radiculopathy is not only acceptable, but in certain cases is preferable to the anterior approach.

Dorsal root entry zone lesions in the treatment of pain related to radiation-induced brachial plexopathy.

Radiation-induced brachial plexopathy (RBP) is a rare (1-2% of irradiated patients) but serious disorder associated with supramaximal irradiation of the brachial plexus. Nerve compression by radiation-induced fibrosis in the absence of tumor recurrence is the hypothesized mechanism of RBP. It appears as severe pain in up to 20% of cases.

The posterior operative approach for cervical radiculopathy.

Cervical disc disease includes acute herniation and chronic disc degeneration with secondary changes in the associated bone. The latter may lead to the spectrum of cervical spondylitic stenosis, which is considered to be multilevel and may be more of a bony disease. Clinically, cervical disc disorders can be divided into several disorders.