Experience in the surgical management of 82 symptomatic herniated thoracic discs and review of the literature.

OBJECT: The authors aimed to develop management strategies for the treatment of herniated thoracic discs and to define indications for selection of surgical approaches. Symptomatic thoracic discs requiring surgery are rare. Between 1971 and 1995, 71 patients with 82 herniated thoracic discs were surgically treated by the authors. The treated group included 34 men and 37 women whose ages ranged from 19 to 75 years, with a mean age of 48 years. The most common sites of disc herniation requiring surgery were from T-8 to T-11. Evidence of antecedent trauma was present in 37% of the patients. Preoperative symptoms included pain (localized, axial, or radicular) in 54 (76%) of the 71 patients, evidence of myelopathy, that is, motor impairment in 43 (61%), hyperreflexia and spasticity in 41 (58%), sensory impairment in 43 (61%), and bladder dysfunction in 17 (24%). METHODS: Radiological diagnosis for the patients in this series was accomplished by means of myelography, computerized tomography myelography, or magnetic resonance imaging. Classification of the disc location into two groups reveals that 94% were centrolateral and 6% were lateral. Evidence of calcification was present in 65% of patients, and in 7% intradural extension was noted at surgery. Ten patients (14%) were found to have multiple herniations. Four surgical approaches were used for the removal of these 82 disc herniations: transthoracic in 49 (60%), transfacet pedicle-sparing in 23 (28%), lateral extracavitary in eight (10%), and transpedicular in two (2%). Postoperative evaluation revealed improvement or resolution of pain in 47 (87%) of 54, hyperreflexia and spasticity in 39 (95%) of 41, sensory changes in 36 (84%) of 43, bowel/bladder dysfunction in 13 (76%) of 17, and motor impairment in 25 (58%) of 43. Complications occurred in a total of 12 (14.6%) of 82 discs treated surgically. Major complications were seen in three patients and included perioperative death from cardiopulmonary compromise, instability requiring further surgery, and an increase in the severity of a preoperative paraparesis. CONCLUSIONS: Review of this series, with the attendant complications, together with evaluation of several contemporary thoracic disc series, has facilitated the authors' decision-making process when considering the comprehensive management of these patients, including the selection of a surgical approach.

Cerebellar contusion associated with type I Chiari malformation following supratentorial head trauma: case report.

Acute presentation of Type I Chiari malformation in children is distinctly rare. An 11 year old male suffered a trauma to the right temporal-parietal region in a tobogganing accident resulting in an open depressed skull fracture. Radiographic evaluation included a Computed Tomographic scan which also demonstrated a significant cerebellar contusion and the presence of subarachnoid hemorrhage in the region of craniovertebral junction. Magnetic Resonance imaging revealed an underlying Type I Chiari malformation. Somatosensory evoked responses shortly following the injury demonstrated slowing of conduction across the lower brainstem. The open depressed fracture was debrided and elevated. Subsequent observation resulted in slow improvement in neurological function. A followup somatosensory evoked potential study performed 21 days following the accident showed improvement in conduction across the craniovertebral junction. The tonsillar ectopia associated with Type I Chiari malformation may predispose to cerebellar, upper spinal and brainstem injury following supratentorial trauma.

Osteosarcoma of the meninges in association with glioblastoma.

Primary intracranial osteosarcoma not originating in the skull is a distinctly rare tumour, as is post-irradiation sarcoma of short latency. The authors report the case of a 56 year old caucasian male who underwent resection of a glioblastoma of the left temporal region and was subsequently administered partial field external beam radiation therapy (XRT) to a total dose of 5940 cGy. Seven months following the completion of XRT, an enhancing region adjacent to the surgical site was noted on followup magnetic resonance images (MRI), one which increased in size on serial studies. Initial biopsy of the dural lesion adjacent to the temporal resection site revealed a sarcoma with a suggestion of osseous differentiation. Subsequent reoperation with resection of the lesion showed it to be a primary meningeal tumour, and histological evaluation of the lesion demonstrated an osteosarcoma. Immunohistochemical staining for p53 protein performed on both the original glioblastoma and the subsequently resected osteosarcoma showed widespread nuclear positivity. The clinical, radiographic and pathologic features of this unusual case are discussed. Meningeal osteosarcoma should be included among the rare secondary sarcomas of the meninges which may be associated with malignant glioma.

Reconstruction of the skull base and cranium adjacent to sinuses with porous polyethylene implant: preliminary report.

Surgical reconstruction of the skull base and cranium adjacent to open paranasal sinuses with alloplastic materials is problematic secondary to an increased risk of implant infection in these locations. The authors report their initial experience with the use of a porous polyethylene implant for closure of defects in these locations in 20 patients, in 14 of these with the implant placed in direct contact with the mastoid or paranasal simuses. The implant is flexible, which facilitates surgical reconstruction of the cranial base, and porous in nature, which enhances soft tissue and bone ingrowth in decrease the risk of infection. The implant is radiolucent on plain roentgenograms and CT, and produces no imaging artifact on MRI. The implant was utilized for a variety of skull base of cranium adjacent to sinus reconstructive applications with no infectious complications, with a follow-up period ranging from 8 to 50 months. This preliminary experience suggests that the alloplast may be a useful adjunct in skull base reconstruction, and further evaluation of its use in this application is warranted.

Use of methylprednisolone as an adjunct in the management of patients with penetrating spinal cord injury: outcome analysis.

OBJECTIVE: Since the results of the Second National Acute Spinal Cord Injury Study were published in 1990, methylprednisolone has become a mainstay in the treatment of nonpenetrating spinal cord injury. Although potential significant relationships between the prompt administration of high-dose methylprednisolone after blunt spinal cord injury and outcome have recently been addressed, the relationship between the prompt administration of high-dose methylprednisolone after penetrating spinal cord injury and outcome remain unanswered. METHODS: To explore this relationship, we performed a retrospective nonrandomized study on a series of 252 patients with penetrating missile injuries to the spine who presented to our institution from March 1980 to July 1993. One hundred eighty-one patients (71%) were treated conventionally without adjunctive steroid therapy before 1990. Sixteen patients followed up during the 13-year study period received steroid protocols that were not consistent with the Second National Acute Spinal Cord Injury Study protocol and were excluded from the study. Since 1990, 55 patients (21%) were treated with intravenous methylprednisolone according to the Second National Acute Spinal Cord Injury Study protocol. All patients were subsequently transferred for rehabilitative care, and prospective evaluations of their neurological status were performed at admission and discharge. RESULTS: The study included 236 men and 16 women (mean age, 25.6 yr). The mean duration of stay for initial hospitalization was 94.6 days, and the mean duration of stay in rehabilitation was 78.6 days. Frankel scores were used to assess outcome (P < 0.05) and were assessed at admission and at the time of definitive discharge from the Spinal Cord Injury Care System. The hypothesis that methylprednisolone therapy significantly improves functional outcomes in patients with gunshot wound injuries to the spine was rejected. Only the total number of days in rehabilitation and the degree of neurological injury at admission contributed significantly to explaining outcome at discharge. CONCLUSION: The administration of methylprednisolone did not significantly improve functional outcomes in patients with gunshot wound injuries to the spine or increase the number of complications experienced by patients during their hospitalizations.

Malignant clival chordoma with postoperative cutaneous metastases.

The authors report the case of a chordoma with malignant cytologic features, presenting as a mass lesion in the clival and infratemporal region at the level of the craniocervical junction in an 8-year-old female. Following gross resection of the mass, the patient subsequently developed distant subcutaneous and peritoneal metastases from the lesion. The rare histologic features, the surgical approach to the lesion, and the follow-up management of this unique case are discussed.

The transfacet pedicle-sparing approach for thoracic disc removal: cadaveric morphometric analysis and preliminary clinical experience.

A number of operative techniques have been described for the treatment of herniated thoracic discs. The transfacet pedicle-sparing approach allows for complete disc removal with limited spinal column disruption and soft-tissue dissection. Fifteen cadaveric spinal columns were used for evaluation of exposure, development of thoracic microdiscectomy instrumentation, and establishment of morphometric measurements. This approach was used to remove eight thoracic discs in six patients. Levels of herniation ranged from T-7 through T-11. Preoperatively, all patients had moderate to severe axial pain, and three (50%) of the six had radicular pain. Myelopathy was present in four (67%) of the six patients. Through a 4-cm opening, the ipsilateral paraspinal muscles were reflected, and a partial facetectomy was performed. The disc was then removed using specially designed microscopic instrumentation. Postoperatively, the radiculopathy resolved in all patients. Axial pain and myelopathy were completely resolved or significantly improved in all patients. The minimal amount of bone resection and muscle dissection involved in the operation allows for: 1) decreased operative time and blood loss; 2) diminished perioperative pain; 3) shorter hospitalization time and faster return to premorbid activity; 4) avoidance of closed chest tube drainage; and 5) preservation of the integrity of the facet-pedicle complex, with potential for improvement in outcome related to axial pain. This technique appears best suited for the removal of all centrolateral discs, although it has been used successfully for treating a disc occupying nearly the entire ventral canal. The initial experience suggests that this approach may be used to safely remove appropriately selected thoracic disc herniations with good results.

Surgical management of lumbar neuropathic spinal arthropathy (Charcot joint) after traumatic thoracic paraplegia: report of two cases.

Two cases of successful surgical treatment of neuropathic spinal arthropathy (Charcot joint) are reported. Each patient was first seen several years after traumatic paraplegia. One patient had progressive kyphosis and the other had severe pain. Symptoms were relieved in both patients after interbody fusion and posterior fixation by using the lateral extracavitary approach to the spine. Both patients remain symptom free several years after the surgery. Fusion should be performed in symptomatic patients with neuropathic spinal arthropathy: this can be combined with posterior fixation in a single stage by using the lateral extra-cavitary approach.

Atlanto-axial stabilization with posterior transarticular screw fixation: technical description and report of 22 cases.

Magerl's technique of combining C1-C2 posterior screw fixation with a supplemental bone-wire fusion has been advocated for the management of atlanto-axial instability. Between October 1990 and August 1992, a modification of this technique was used in the treatment of 22 patients with this disorder. In the absence of spinal deformity or neoplastic disease, screw fixation and bony fusion were used alone without associated wiring, thus avoiding the risk of neural injury resulting from the sublaminar passage of wire and the retrodisplacement of ventral structures. Patient ages ranged from 30 months to 80 years; follow-up ranged from 5 to 27 months, with a mean of 14.9 months. The causes of the instabilities were as follows: eight cases of nonunion of Type II odontoid fracture, four cases of rheumatoid arthritis, three cases of tumor, two cases of ligamentous instability, two cases of pseudoarthrosis after bone-wire fusion, two cases of halo noncompliance, and one case of Os odontoideum. All 20 patients who underwent fusion were placed in a Philadelphia collar for 12 weeks. Nineteen of 20 (95%) patients achieved solid fusion. Twenty-one of 22 (95%) had significant reduction in preoperative pain. No patient developed myelopathy or bulbar findings. The one intraoperative complication was an inability to achieve secure screw purchase on one side that required unilateral screw placement with a Gallie fusion-using cable. Postoperative complications included one patient with a superficial wound infection that resolved after local debridement and antibiotics and suboccipital numbness in two patients. Progression of spinal deformity, screw pullout or breakage, and neurological or vascular complications did not occur.(ABSTRACT TRUNCATED AT 250 WORDS)