Resolution of spontaneous spinal epidural hematoma without surgery: report of two cases.

STUDY DESIGN: Case report. OBJECTIVE: To report two cases of spontaneous spinal epidural hematoma that completely resolved, clinically and radiographically, without surgical treatment. SUMMARY OF BACKGROUND DATA: The treatment of spinal epidural hematoma is usually surgical. Spontaneous spinal epidural hematoma is an uncommon phenomenon and may be of uncertain cause. METHODS: One patient with acute onset of complete quadriplegia and another with complete paraplegia caused by spontaneous spinal epidural hematoma were treated without surgery. RESULTS: Both patients recovered nearly completely with respect to their neurologic function at 3-month follow-up. No source of hematoma was ever identified. CONCLUSIONS: Spontaneous spinal epidural hematoma should be considered in the differential diagnosis of sudden onset of spinal cord compression in association with back pain. Patients initially presenting with severe neurologic dysfunction are potential candidates for conservative management if they demonstrate rapid and progressive improvement in neurologic function. Patients treated in this manner can have nearly complete restoration of function.

Experimental use of somatosensory evoked potential for intraoperative identification of spinal cord blood supply.

The role of sensory evoked potentials (SEPs) to be used intraoperatively to reliably predict spinal cord ischemia, caused by interruption of intercostal and of lumbar and sacral arteries, was evaluated in a canine model. Two groups were assessed: (A) interruption of intercostal arteries (n = 6) and (B) interruption of all posterior branches (n = 6). SEPs were evaluated intraoperatively as control and interruption of posterior vessel groups, and at 18-22 h after surgery. Neurologic assessment was performed preoperatively and 18-22 h postoperatively by modified Tarlov criteria. Morphological assessments were also performed. The assessment of the groups demonstrated prolongation of latency and loss of amplitude of SEP, but individual changes of SEPs were poor predictors of paraplegia. Ultrastructural changes correlated with neurologic findings. SEPs were unreliable for intraoperative identification of vessels critical to spinal cord blood supply, possibly related to anatomically different blood supply of sensory and motor tracts.

Features of spinal cord injury in Taiwan (1977-1989).

In order to establish an etiological and statistical base for spinal cord injuries, 1,617 spinal cord injured patients admitted to the Chang Gung Memorial Hospital in Taiwan during the period of 1977 to 1989 were reviewed. The most common causes of injury were pedestrian (29.31%) and motorcycle (28.88%) accidents. The greatest incidence of injury was in the 26-35 year age group. The complete tetraplegic patients had the highest mortality rate (26.5%). Additional features studied were the time of occurrence and pattern of injury. Information gathered from this study suggest the need to establish a Spinal Cord Injury Prevention Program, to develop a Prehospital Care System and set up comprehensive Spinal Cord Injury Units in Taiwan. We expect this study to be adaptable to other similar developing countries.

Evaluation of the operating room as a surgical teaching venue.

Surgical educators are facing changes in residency training that have a direct impact on the opportunity that surgeons and residents have for clinical teaching and learning. The knowledge required of residents continues to escalate. Further, as resident positions are reduced, the opportunity for inter-resident education is decreased. Increased service-to-education ratios may result in resident discontent unless surgeons take an active role in the resident's educational experience. The purpose of this study was to examine the educational activities that occur during the operating-room experience. Technical training in the procedure being done was the primary educational activity, but there were long periods when no form of education was taking place. The operating room provides the teacher and learner with uninterrupted time together, and this time can and should be used for clinical teaching and learning.

International education: a third alternative.

Education is the key to the delivery of medical care in the developing world. The traditional methods of educating specialists from developing countries have serious drawbacks. A third alternative is that educators from the developed countries participate locally in the education and practice of neurosurgery. The author reports his experience of living and working in Taiwan.

Surgical treatment of spontaneous cerebellar hemorrhage.

UNLABELLED: Spontaneous cerebellar hemorrhage accounts for 5%-10% of intracerebral hemorrhage in most series. From June 1979 to June 1983 we had 26 surgical cases of spontaneous cerebellar hemorrhage. There were 15 men and 11 women. The typical history was sudden onset of severe headache, vomiting, dizziness, and inability to walk. Disturbance of consciousness was usually a late feature. Common signs were truncal ataxia, nystagmus, conjugate eyeball deviation, small miotic pupils with or without light reflex and abducens palsy. Surgical indications are (a) disturbance of consciousness, (b) signs of brainstem compression and (c) hematoma with transverse diameter greater than 3 cm. The overall surgical mortality was 34.6%. Twenty-two patients underwent suboccipital craniectomy to evacuate hematomas with or without ventriculostomy; mortality rate was 27%. Four patients underwent ventriculostomy only; mortality was 75%. Causes of death were (a) brainstem failure, six patients; (b) airway obstruction, one patient; (c) chest infection, one patient; (d) chronic renal failure, one patient. CONCLUSION: (a) suboccipital craniectomy to evacuate the hematoma is the most effective procedure where treatment is indicated; (b) the clinical recovery of the survivors show that 31% return to work, 38% are moderately disabled but take care of themselves, and 31% remain dependent on others; (c) deeply comatose patients may still benefit from early operation.

Transoral anterior decompression for treatment of unreducible atlantoaxial dislocations.

Three cases of nonreducible atlantoaxial dislocation are reported. Transoral anterior decompression followed by posterior fusion was done with good results in all three cases.

Microangiographic study of experimental spinal cord injuries.

The pathology of spinal cord injury has been studied in 34 rabbits and 5 dogs with attention focused on the condition of the microvasculature during the evolution of neuronal and axonal degeneration and necrosis. The animals were killed and perfused arterially with colloidal barium from 10 min to 14 days after a controlled spinal injury. Microradiographs of the injured tissues were obtained and compared with corresponding histological sections. Microangiography at 7 to 14 days defines two zones in the injured spinal cord. Zone 1 is located in the posterocentral part of the cord. Capillaries in this region progressively lose their ability to conduct blood and perfusate over the first 4 hours. Degenerative changes in neurons are visible by 1 hour after injury. Necrosis of all elements including capillaries ensues. Zone 2 surrounds Zone 1. Microvascular patterns are normal in Zone 2 although neuronal and axonal degeneration is severe. Pericapillary hemorrhages which occur as early as 10 min after injury in Zone 1 and become progressively larger over the first 4 hours seldom are seen in Zone 2. The evidence indicates that at all times in the pathogenesis of spinal cord injury the microvasculature in Zone 2 is capable of perfusion. Degeneration of neural structures either precedes microvascular breakdown (Zone 1) or occurs in the absence of microvascular disruption (Zone 2). Recovery of damaged neurons and axons depends upon a preserved microcirculation.