Helping patients decide about back surgery: a randomized trial of an interactive video program.

STUDY DESIGN: A randomized trial of 100 patients with low back pain who were potential surgical candidates. OBJECTIVES: To determine whether an interactive videodisc with a booklet is superior to a booklet alone for informing patients about back surgery. SUMMARY OF BACKGROUND DATA: Substantial geographic variation has been observed in lumbar spine surgery. Informed patient preferences should play an important role in decisions about surgery. However, little is known about optimal strategies for informing patients. METHODS: Subjects were randomized to receive an interactive videodisc (with a booklet) or a booklet alone. A knowledge test administered at baseline and follow-up was used to measure improvement in knowledge about treatment options for lumbar spine problems. Patients' reactions to the videodisc and booklet and preferences for treatment were also assessed. RESULTS: The patients' knowledge improved after exposure to either intervention. Multivariate analyses adjusted for baseline score, age, education, gender, and diagnosis showed a significant advantage for the videodisc with booklet over the booklet alone. The videodisc-booklet group showed significantly greater gains in knowledge among subjects with the worst baseline knowledge scores. A larger proportion of subjects in the videodisc-booklet group rated the materials easy to understand (93% vs.- 72%,P = 0.04), containing the right amount of information (93% vs.- 80%,P = 0.3), and adequate to assist in choice of treatment (75% vs.- 51%,P = 0.2). Those who viewed the videodisc expressed a somewhat lower preference for surgery than those who received the booklet alone (23% vs.- 42%,P = 0.4). CONCLUSIONS: Both the booklet alone and the combination of videodisc and booklet improved knowledge. The combination produced greater knowledge gains than the booklet alone for the subgroup with the least knowledge at baseline. Patients preferred the combination and had a slightly lower preference for surgery if they had viewed the video presentation. For some patients, the video may enhance involvement in clinical decisions.

Chlorpromazine treatment for neurogenic pulmonary edema.

A patient with neurogenic pulmonary edema was successfully treated with the alpha-blocking agent, chlorpromazine. A pathophysiologic basis for this drug's efficacy is discussed.

Intraoperative neurosonography: application and technique.

Intraoperative neurosonography was performed in 44 patients with contact transdural or transgyral scanning technique. Localization of intracranial pathology included primary brain tumors (24), metastatic tumors (11), aneurysms (two), abscesses (two), arteriovenous malformation (one), thrombosed arteriovenous malformations (two), and plasmacytoma (one). Sonographic guidance was used in transdural decompression of three cystic lesions, therapeutic and diagnostic aspiration of two abscesses, and biopsy of three solid lesions. The expertise of the physician-sonographer with sonographic equipment facilitates accurate and expedient intraoperative neurosurgical localization of pathology.

Physiological evaluation of the effect of fascicular ligation on neuromas in the rat.

Microfascicular double ligation and interligature heat sealing has been clinically successful in relieving neuroma pain. In rats, we found that this technique had no effect on the abnormal activities (such as mechanosensitivity and spontaneous activity) of single myelinated axons from neuromas or on their conduction velocity distribution. Assuming that the clinical success of this method is not fortuitous, we challenge the prevailing theory of the relationship between these abnormal unit activities and pain.

Intraoperative ultrasound detection of metastatic tumors in the central cortex.

Real-time sector ultrasonography precisely located metastatic tumors of the central motor cortex during craniotomy in two patients. In these two cases, the only surface abnormality was swelling of several overlying gyri. Intraoperative ultrasonography precisely located the 1.5- and 2.5-cm-diameter tumors to a position below a specific gyrus, enabling the surgeon to excise the tumors through small, accurately placed cortical windows. The precise location minimized exploratory probing and the size of the cortical incision required to identify and remove the tumors. This technique will have general application in similar situations when the cortical surface gives no indication of underlying tumor location. By charting the best trajectory for the surgical approach, this technique may replace a variety of stereotactic and computed tomography-guided techniques for biopsy of deep brain tumors.

Cerebellar hemorrhage as evaluated by computerized tomography.

Nine patients with cerebellar hemorrhage were examined initially with computerized tomographic (CT) scanning. CT appearance in combination with clinical state determined therapy. The most common presenting symptoms were headache, ataxia and vomiting, usually with alterations in the level of consciousness. Three patients were comatose. In five patients surgical evacuation of the hematoma was done and one of these died. Two who were moribund at presentation were not operated on and succumbed. The remaining two did not require operation and recovered. Early investigation with CT scanning considerably aided decisions as to the appropriate method of treatment.

Comparison of percutaneous radiofrequency gangliolysis and microvascular decompression for the surgical management of tic douloureux.

Forty-two patients with tic douloureux underwent posterior fossa craniectomy and microvascular decompression (MVD) or partial rhizotomy of the trigeminal nerve and were followed an average of 25 months after operation. Thirty-six patients were found to have anatomical distortions of the nerve by an artery, vein, bony prominence, or a combination of factors, and 30 patients (83%) of this groups hav remained pain-free postoperatively. Six patients had no discernible pathological condition at the time of operation and underwent partial trigeminal rhizotomy. No patient underwent repeated MVD or rhizotomy, although 4 patients whose pain recurred after MVD underwent rhizotomy at a second operation. Eight of the 10 patients treated by rhizotomy are currently pain-free. The overall success rate of the entire group is 90%; 2% experienced a complication, and there was 1 perioperative death. Seventy-eight patients with tic douloureux who underwent 92 percutaneous radiofrequency trigeminal gangliolysis (PRTG) procedures were evaluated on average of 56 months postoperatively. Sixty-eight per cent of these patients when evaluated 1 year postoperatively were pain-free. However, only 35% of the PRTG procedures resulted in continued pain relief 5 years after operation. Twelve of the 78 patients (15%) required repeat gangliolysis because of recurrent tic pain. Considering all 78 patients treated with 92 PRTG procedures, 64% were pain-free at follow-up examination. PRTG was associated wtih an 8% risk of complications, which included anesthesia dolorosa, corneal anesthesia with keratitis, and significant facial paresthesias. Both PRTG and MVD have advantages. MVD should be considered because: (a) it attacks what is believed to be the primary etiology of tic douloureux, (b) the trigeminal nerve is preserved, (c) postoperative pain relief dose not depend upon the production of sensory deficit, and (d) it may have a greater potential for producing long-lasting pain relief. However, PRTG has other advantages: (a) it avoids the risks of craniectomy, (b) it is repeated easily if tic pain recurs, (c) morbidity is minimal and there is essentially no risk of mortality, and (d) it is much less expensive.

Spinal epidural neoplasia. A 15-year review of the results of surgical therapy.

The outcome following decompressive laminectomy and spinal irradiation has been evaluated in 104 consecutive patients with epidural metastatic neoplasia, using broad criteria for successful outcome. Of patients so treated, 33% were benefited, while 23% became worse. Both tumor histology and the preoperative neurological status were important factors in determining the response to this therapy. The authors review the surgical and radiotherapeutic literature in the treatment of this condition, and conclude that there is no clearly established superiority of laminectomy followed by irradiation over radiotherapy alone. Specific indications for surgery exist if prior histological confirmation of malignancy is lacking, if there is neurological deterioration during radiotherapy, or if there are recurrent symptoms referable to a previously irradiated metastasis. Surgery is also indicated if facilities for prompt administration of radiotherapy are unavailable.

Pathophysiology of trigeminal neuralgia.

Tic douloureux is a painful affliction of man without known similarities to diseases in infrahuman species or to other human afflictions. It seems to be associated with structural abnormalities encroaching upon the trigeminal nerve, gasserian ganglion, or root entry zone. The multiple unique features of tic douloureux can be explained by a theory which is based upon presynaptic inhibition and reflection sites due to focal changes in axon diameter or myelination. We believe that this theory satisfactorily explains the varied phenomena of tic douloureux and is compatible with the limited anatomical and physiological data relevant to tic douloureux. It makes use of known physiological and anatomical concepts. It is capable of verification or refutation by experimental means.

Giant aneurysm of the middle cerebral artery.

A case of a giant aneurysm of the middle cerebral artery, (4.5 X 4.5 X 9.5 CM) presenting as a mass lesion, which was successfully excised is described. This case is compared to the few previous accounts of giant aneurysms of the middle cerebral artery larger than 3 cm in diameter.

Percutaneous radiofrequency trigeminal gangliolysis in the treatment of tic douloureux.

The treatment of tic douloureux was dramatically altered in 1962 with the demonstration that carbamazepine (Tegretol(R)) alone or in combination with diphenylhydantoin sodium (Dilantin(R)) was effective in controlling the painful paroxysms. However, 30 percent of the patients so treated have not been successfully managed and some type of surgical therapy is required to control their pain. A wide variety of surgical alternatives are available but they all trade a sensory deficit for pain relief and have a significant risk of morbidity and mortality. Experience with percutaneous radiofrequency trigeminal gangliolysis has indicated that this new technique is capable of producing lasting relief of tic douloureux in as many as 95 percent of the patients. To date there have been no deaths from this procedure and a very low incidence of minor complications. It achieves this high success rate at the expense of only partial sensory deficits restricted to a circumscribed area of the face. No other surgical alternative carries such a high long-term success rate with a low complication rate. We believe that percutaneous radiofrequency trigeminal gangliolysis has become the surgical treatment of choice for tic douloureux.