Management of nonsmall cell lung carcinoma with solitary brain metastasis.

Cushing's group, operating on metastatic brain tumors in the 1920s, was the first to point out that lung cancer (usually adenocarcinoma in an upper lobe) was the most common primary tumor. Excision of a solitary metastasis could result in long-term survival. Magilligan and coworkers (J Thorac Cardiovasc Surg 1976;72:690) introduced the modern era of large series of combined lung-brain resection with low mortality (3%) and a 5-year outcome of 21%. Our results (92 patients) confirm their experience. Presenting symptoms were pulmonary (53), synchronous (28), or neurologic (11). Nonsquamous cell (48) predominated. Pulmonary resections (45) were pneumonectomy (five), lobectomy (27), segmentectomy (five), and wedge biopsy (eight). Craniotomy (68) and irradiation resulted in recurrence in seven patients. There was no operative mortality. The survival rate after curative lung and brain resection (27) was 52% at 1 year, 35% at 2 years, and 21% at 5 years. Median survival in noncurative combined resection (eight), craniotomy only (27), thoracotomy only (eight), or no surgery (22) groups, with or without irradiation or chemotherapy, averaged 6.4 months. Every effort should be made to give patients with this syndrome the benefit of combined surgery, which was not offered or agreed on in more than a third of our cases.

Computed tomographic discography in the evaluation of extreme lateral disc herniation.

Thin section, high resolution computed tomographic (CT) scans of the lumbar spine produce images that can show herniated intervertebral discs without intravenous or intrathecal contrast enhancement. With this technique, the diagnosis of posterolateral and midline herniation has been greatly facilitated. This communication reports the use of CT discography in the preoperative evaluation of two patients who were shown at discography and proven at operation to have extreme lateral disc herniations.

Acrylic stabilization of the cervical spine for neoplastic disease: evolution of a technique for vertebral body replacement.

The resection of collapsed cervical vertebral bodies affected by malignant lytic lesions often requires innovative methods for stabilization. Over the years, immediate stabilization of the cervical spine has been achieved with acrylic bridges, preformed metallic placement bodies, fibular strut grafts, and other aids. Because acrylic bonds poorly to adjacent bony structures, techniques to assure the adequate fixation of an acrylic bridge between resected vertebral bodies are needed. The possible progression of disease in adjacent bone prompts us to maximize the amount of internal fixation with rods or pins to assure stability. Lasting stability has become more important as the longevity of cancer patients has been increased by multimodality therapy. We report our technique for treating cancer patients with acrylic and pin fixation of the cervical spine after vertebral body excision by the anterior route. Certain modifications of the technique may have advantages over previously reported procedures. Our series of six cases demonstrates the evolution of a technique that allows relatively rapid and easy decompression of the cervical spinal cord and provides immediate stability of the cervical spine. Our indications and contraindications for this procedure are also discussed.

Enflurane anesthesia and changes of intracranial pressure.

Enflurane has been recommended by some as an ideal agent for use in neuroanesthesia. There is no statistically significant alteration of normal intracranial pressure with enflurane anesthesia. However, supporting a clinical impression, this study demonstrates in dogs that enflurane will significantly increase an already elevated intracranial pressure.