Selection criteria and outcome of operative approaches for thoracolumbar burst fractures with and without neurological deficit.

Criteria for choosing operative techniques for the treatment of thoracolumbar burst fractures remain disputed, particularly in neurologically intact patients. A retrospective study of 25 patients with thoracolumbar burst fractures was performed to assess fracture characteristics, operative approaches, fixation, radiographic results, and neurological, functional, and pain outcomes. Anterior corpectomy, allograft strut, and plate fixation were performed in 14 patients with or without neurological deficit when vertebral compression or canal encroachment was at least 40% or kyphosis was 15 degrees or more with a stable posterior column. In nine cases, an anterior operation and a posterior segmental fixation were combined for similar deformity and three-column instability. Posterior transpedicular decompression, fixation, and fusion were used primarily for two symptomatic patients with less than 40% encroachment and at most 40% compression. Overall, 21 patients (84%) were walking and 18 (72%) were continent at follow-up evaluation (mean 16.3 months) versus eight (32%) and 11 (44%) at presentation, respectively. Preoperatively, 17 patients experienced neurological deficit; 16 improved and 12 increased one Frankel grade. No patient deteriorated. Prior employment or activity level was resumed by 19 patients (76%) and only four patients professed incapacity. Pain was eliminated after 18 procedures (72%), all anterior or combined approaches. Restoration of anatomical alignment (< 5 degrees) was achieved in 19 cases. No anterior construct failed and only one patient treated posteriorly had postoperative kyphosis progression. Operative morbidity occurred in three cases (12%). Satisfactory neurological and functional outcomes were achieved in a majority of patients with thoracolumbar burst fractures after correction of canal compromise, middle column compression, and attendant deformity. These results indicate that anterior decompression and a weight-bearing strut graft are critical to clinical success in patients with significant vertebral destruction.

Outcome analysis for adults with spondylolisthesis treated with posterolateral fusion and transpedicular screw fixation.

The outcomes of 52 adult patients with symptomatic low-grade spondylolisthesis treated with autologous posterolateral arthrodesis and pedicle screw fixation were retrospectively reviewed. Although a 90% rate of successful fusion was obtained using this technique, only 60% of patients were considered to have good outcomes. Treatment failures consisted mostly of back pain and were not predicted by preoperative symptoms. Compensation claims and smoking had very significant adverse impacts on both employment and pain results despite high fusion rates, particularly in patients under the age of 55 years. Overall, patients who required more than one operation demonstrated poor outcomes compared to those who only needed one. However, patients with at least two prior operations or preoperative pseudoarthrosis fared particularly poorly, whereas those who had undergone only one prior surgery and had no attendant compensation issue reported good results. A trend toward poor outcome was observed in patients with postlaminectomy spondylolisthesis, versus those with isthmic or degenerative etiologies. Gender did not exert an impact on outcome. The authors conclude that autologous posterolateral arthrodesis combined with pedicle screw fixation resulted in a high fusion rate, and contributed to successful outcomes in the treatment of certain subgroups of adults with spondylolisthesis. In the absence of other risk factors, patients may obtain significant benefit from surgery despite older age and a single failed operation. Careful patient selection appears critical in predicting the maximum benefit from this technique.

Cerebral revascularization with an artificial graft: long-term follow-up and discussion of the role of graft pretreatment with modified host endothelial cells.

Controversy remains regarding the effectiveness of EC/IC bypass for the prevention of stroke and the authors believe that some studies suggest that a subcategory of patients disabled by transient flow-related symptoms may benefit from surgery. The authors present a 7 1/2 year follow-up analysis of a patient who had undergone an EC/IC bypass from the proximal extracranial carotid to the middle cerebral artery using a 4 mm Gore-Tex prosthesis. Following his death from pulmonary sepsis, the graft was retrieved. Pathological and electron microscopic findings are reviewed.

Villaret's syndrome: a report of two cases.

The syndrome resulting from lesions of the lower four cranial nerves (CN) and the cervical sympathetic chain is known as Villaret's syndrome. We report two cases of the syndrome and emphasize the localizing value of this constellation of signs. The second case is unusual because involvement of the cervical sympathetic chain produced sympathetic overactivity, instead of the usual sympathectomy effect. Increased sympathetic outflow expressed as pupillary dilation, widened palpebral fissure, and facial sweating (the Claude Bernard syndrome) usually occurs as an early manifestation of apical thoracic tumors and has not been previously associated with Villaret's syndrome.

Polytetrafluoroethylene interposition grafts in vertebral to carotid artery transposition. A long-term follow-up study.

Eight patients undergoing an end-to-side vertebral artery (VA) to common carotid artery transposition between August, 1979, and July, 1982, had a polytetrafluoroethylene (PTFE) interposition graft placed when a direct anastomosis was believed not to be satisfactory. Five of these patients are living; clinical and radiographic follow-up studies over periods ranging between 54 and 82 months show that their transpositions are patent. Two patients died perioperatively, one from an acute anterior myocardial infarction and the other from acute VA occlusion with a propagating thrombus. A third patient died of myocardial infarction 20 months after graft placement; the anastomosis had been found patent at 12 months. This report gives the clinical and radiographic follow-up results in a previously reported group of patients with PTFE interposition grafts. Some of these patients have been followed for over 6 years after surgery: the average radiographic follow-up period in the five survivors is 60 months, and all grafts are patent without evidence of progressive stenosis. Expanded PTFE appears to be an acceptable material for short interposition grafts in operations involving the VA; however, direct artery-to-artery anastomosis is preferred. The results of longer PTFE grafts in reconstructive cerebrovascular surgery have not been adequately studied.

Extracranial surgical procedures in the management of vertebrobasilar insufficiency.

Vertebrobasilar insufficiency is an important syndrome in the spectrum of cerebrovascular disease. Its clinical importance and the frequency of its clinical manifestations are often underestimated. Our experience with a large population of patients having extensive cerebrovascular disease has led us to recognize two classes of vertebrobasilar insufficiency--simple and complex--and, also, to recognize that vertebrobasilar insufficiency is often associated with disease in multiple extracranial vessels. Until recently, direct approaches to the vertebral artery have been underutilized for these patients. In fact, there has been a tendency either to relegate patients with vertebrobasilar disease to medical follow-up or to surgical procedures upon the carotid system. We believe that the resurgence of neurosurgical interest in the vertebrobasilar system is most appropriate. Furthermore, the active interest that neurosurgeons are now taking in developing procedures for managing extracranial vertebral artery problems is in the best interest of patients with cerebrovascular disease. We believe that careful neurosurgical evaluation of patients with simple and complex vertebrobasilar insufficiency will lead to appropriate selection of candidates for vascular reconstruction of the vertebral system. Finally, we believe that vertebral artery to common carotid artery transposition, and its variations, is a procedure that has an important role in the management of cerebrovascular disease.