Cervical spondylotic myelopathy: functional and radiographic long-term outcome after laminectomy and posterior fusion.

OBJECTIVE: To evaluate the long-term efficacy of cervical laminectomy with posterior lateral mass fusion/fixation in the treatment of patients with cervical spondylotic myelopathy (CSM). METHOD: Twenty-five patients treated for CSM by laminectomy and lateral mass fusion at the Division of Neurosurgery at The Ohio State University between 1989 and 1994 were studied retrospectively. Only patients with longer than 2-year postoperative follow-up durations were included. At follow-up examination, each patient completed an SF36 questionnaire, underwent a physical examination, underwent plain radiography showing the spinal curvature with plate and screw position, and underwent magnetic resonance imaging of the cervical spine, which evaluated dural sac decompression and spinal cord abnormalities. Patient-generated data were used for outcome measurements. RESULTS: The mean follow-up duration was 47.5 months. Good outcome was defined by the presence of three criteria: ability to walk unassisted (Grade IIIA or better), ability to write unassisted, and ability to manage buttons and/or zippers unassisted. The inability to meet these criteria was defined as a poor outcome. Two patients (8%) experienced complications that resulted from the surgery. There was no instability or progression to significant kyphosis. Lesions that were hyperintense on magnetic resonance images did not correlate with outcome. Eighty percent of the patients achieved good outcomes, and 76% had improved myelopathy scores. None of the patients had late neurological deterioration. Patients with better neurological statuses at the time of surgery (Grade IIIA or better) were more likely to improve (P < 0.0001); the likelihood of a change in status for those starting with poorer grades (IIIB or worse) was not statistically significant (P < 0.08). CONCLUSION: Cervical laminectomy with posterior fusion/fixation proved useful in the treatment of patients with CSM with straight or lordotic spines and multilevel compression. This therapy addresses the dynamic and compressive forces that are important in the pathogenesis of CSM, resulting in minimal complications and possible improvement in long-term outcomes.

Lessons from atypical groin pain: presentation and treatment of a schwannoma.

A 16-year-old boy presented with pain in the right knee, groin, and hip after a touch football game. He was initially diagnosed as having a medial collateral ligament sprain of the right knee and an adductor muscle strain. Despite standard conservative therapy, he had persistent hip pain and migratory pain to the right lower abdomen and flank. A bone scan and abdominal CT scan were negative, but MRI revealed a mass in the cauda equina at L3-4, confirmed with myelography. A benign schwannoma was surgically excised without neurologic sequelae. The patient resumed daily activities 5 weeks after surgery.

Interpretive risks: the use of the Hopkins Symptom Checklist 90-Revised (SCL 90-R) with brain tumour patients.

Patients with brain tumours often report distress. Interpretive problems ensue when measures normed on healthy persons are utilized to quantify distress. This study investigated potentially spurious elevations on the Hopkins Symptom Checklist 90 Revised (SCL 90-R). Responses of 17 patients were obtained prior to aggressive chemotherapy. Traditional interpretation indicated that 47% of the patients endorsed clinical levels of somatization, 53% obsessive-compulsive and 59% psychotic disorders. Elevations were attributable to common consequences of brain tumours, medication and the emotional reaction to prognosis. Conventional interpretation would lead to inappropriate classifications. The majority of SCL 90-R item endorsements were significantly different than those of the norm group. Appropriate interpretation of scores is discussed.

Quantitative outcome and radiographic comparisons between laminectomy and laminotomy in the treatment of acquired lumbar stenosis.

OBJECTIVE: The objective of this study was to conduct a comparative quantitative analysis of outcomes, radiographic findings, and magnetic resonance imaging results after laminectomy or laminotomy was performed for patients with lumbar stenosis. Such as analysis had not previously been conducted. METHODS: Twenty-six patients with no exclusion criteria who were treated surgically for acquired stenosis at the Division of Neurological Surgery at The Ohio State University from 1990 to 1993 were studied retrospectively. At follow-up examinations, each patient completed a detailed questionnaire that included visual analog scales, functional assessments, and the medical outcome study short form health survey, SF-36. Each patient underwent plain static and dynamic radiography that detailed vertebral body sagittal listhesis and rotation and magnetic resonance imaging that evaluated dural sac compression. RESULTS: The mean follow-up duration was 36.7 months. Good outcome was defined by the presence of three criteria: no greater than mild leg pain (Grades 0-4), the ability to walk more than one block without developing lower extremity pain, and the ability to walk without assistance devices. Fifty-eight percent of the patients who had undergone laminectomies and 50% of the patients who had undergone laminotomies had good outcomes. All were judged to have had adequate decompression. The average maximum postoperative listhesis was 17.3 +/- 9.9% in the laminectomy group and 17.6 +/- 12.5% in the laminotomy group. In contrast to some previous studies, pre- or postoperative listhesis was not statistically related to outcome in either group. Patients in each poor outcome category seemed to have worse comorbid medical conditions than did patients in the good outcome category. The SF-36 measurements of poor functioning because of health factors and bodily pain correlated somewhat with poor outcomes in the patients who had undergone laminectomies. In patients who had undergone laminotomies, the only statistically significant finding among the outcome groups was the effect of poor emotional health on activity for the patients with poor outcomes. CONCLUSION: This study indicates that laminotomy can adequately decompress lumbar canal stenosis, that laminectomy and laminotomy have the same degree of postoperative listhesis, and that the quantitative outcome of any treatment for lumbar stenosis is dependent not only on surgical factors but also on comorbid physical and psychological factors.

Occipitocervical fixation in nontraumatic upper cervical spine instability.

Ten patients requiring occipitocervical fixation were reviewed: five were unstable secondary to rheumatoid arthritis, one had Klippel-Feil, and four had neoplastic disease. Patients with nonneoplastic disease improved, having decreased pain, decreased paresthesias, and increased ambulation. Patients with neoplastic disease improved significantly after the surgery, but eventually died from different tumors. The technique found to be most efficient was the placement of an intraoperatively contoured Luque rectangle wired from the occiput to appropriate cervical spine levels.

Steroid-induced remission in primary malignant lymphoma of the central nervous system.

A case of primary malignant lymphoma of the central nervous system is described in which lesions seen on computed tomography scans disappeared, and clinical remissions occurred with the administration of corticosteroids. The tumor affected the region of the fourth ventricle and parietal and frontal lobes. In our patient, three remissions occurred over a span of 24 months, each in conjunction with corticosteroid administration. This supports other observations that steroids alter the natural history of primary malignant lymphoma of the central nervous system, leading to both radiologic and clinical remissions.