Surgery for paediatric thoracic outlet syndrome.

The effectiveness of operative treatment of paediatric thoracic outlet syndrome (TOS) has been analysed, and an attempt made to improve the definition of the condition in terms of presentation, aetiology and diagnosis. A retrospective review of postoperative pain, functional capability and overall outcome was carried out on 13 patients (<18 years) treated by a single surgeon. In 20 operations, 17 were scalenotomies, and three were transaxillary rib resections (TARRs). Follow-up was 6-96 months post-operatively. Surgery alleviated many TOS symptoms, especially vascular compromise, although pain resolution was inconsistent and that of motor deficit poor. Mean functional improvement was good, and overall operative outcomes excellent. Therefore, surgery was successful for paediatric TOS in this series. Anatomical anomalies and sport participation may be related to early onset of TOS in many paediatric patients.

Amyloid in neurosurgical and neurological practice.

The amyloidoses are a diverse group of diseases characterized by the deposition of specific proteins with distinct affinity to the dye Congo red, collectively called amyloid. The amyloidogenic proteins have acquired an abnormal, highly ordered, beta-pleated sheet configuration with a propensity to self-aggregate. The amyloid may be distributed in different organs with a remarkable diversity. Two broad categories of amyloidoses are recognised: The systemic (consisting of the primary or light chain form, the secondary or reactive form and the familial or hereditary form) and the localised that target specific organs. A tropism of amyloid proteins to the neural tissue produces certain patterns of central nervous system diseases: cerebral amyloid angiopathy, a substrate of spontaneous intracerebral haemorrhage; mature neuritic plaques found in Alzheimer disease and a subset of prion diseases; a topographically restricted accumulation of extracellular proteins giving rise to tumour-mimicking masses, the amyloidomas; and finally, spinal extradural amyloid collections that occasionally are found in the context of rheumatoid arthritis. In this review article we present original illustrative cases of amyloid diseases of the central nervous system that may be encountered in neurosurgical and neurological practice. Molecular aspects and clinical management problems are discussed.

Transient global brainstem dysfunction after microvascular decompression of the trigeminal nerve.

Microvascular decompression of the trigeminal nerve root entry zone has become a standard treatment for trigeminal neuralgia. It has been widely reported with a low morbidity. This case report details an unusual and previously unreported complication of this procedure.

Internal fixation for osteomyelitis of cervical spine: the issue of persistence of culture positive infection around the implants.

BACKGROUND: We describe the management of osteomyelitis of the cervical spine, utilizing internal fixation with subsequent removal and culture of the implants. Four out of five patients had evidence of bacterial colonisation in close proximity to the internal fixation device. METHODS: Five consecutive patients (all female, ranging in age from 50 to 74 yrs) presenting with unstable cervical osteomyelitis were treated by surgical decompression, primary internal fixation followed by three months of intravenous antibiotics. The internal fixation was removed in 4 out of 5 cases within a year of stopping the intravenous regime. The remaining patient was deemed medically unfit for further operation. Multiple specimens from the screw sites were taken at the time of metal removal. A final course of oral antibiotics was prescribed based on the results of these specimens. FINDINGS: Four patients, who had removal of the implants, had positive cultures growing different bacteria from the primary infection, at the time of removal of the implant. None of the patients developed instability after removal of the implant. INTERPRETATION: Asymptomatic bacterial colonisation of a metallic implant has profound management implications. We recommend long-term oral antibiotic regimes after insertion of internal fixation devices in the face of infection and eventual removal of these implants and microbiological re-sampling.

Craniocervical fusion for rheumatoid arthritis: comparison of sublaminar wires and the lateral mass screw craniocervical fusion.

The majority of rheumatoid arthritis patients with C1/2 instability causing neck pain and neurological compromise can be treated with unisegmental fusion. However, a minority will require decompression and more extensive craniocervical fusion. Two cohorts of patients with rheumatoid arthritis requiring decompression and craniocervical fusion were included in a retrospective study comparing sublaminar wiring (Ransford Loop, n = 10, follow-up = 36 +/- 9.5 months) and lateral mass screws (Cervifix system, n = 11; follow-up = 39.7 +/- 7.9 months). Both cohorts of patients experienced significant improvements in high cervical pain scores [McGill 5-point score; preop = 4.5 +/- 0.75 for Cervifix and 4.5 +/- 0.75 for Ransford loop; postop = 1.17 +/- 0.9 (p = 0.003) for Cervifix (at 39.7 months +/-7.9) and 2.8 +/- 1.6 (p = 0.011) for Ransford loop (at 36 +/- 9.5 months)]. Lateral mass screws for craniocervical fusion (seven out of 11 pain free) appear to produce better early results for rheumatoid arthritis patients suffering high cervical neck pain than sublaminar wire techniques (three out of 10 pain free).

Neurocytoma of the thoracic spinal cord.

Central neurocytoma is an unusual tumour that arises in the supratentorial ventricular system of young adults. Similar lesions, termed simply neurocytoma, have been described at a variety of locations outside the ventricular system. Here, we report the case of a 50-year-old man who presented with pain and a rapidly progressive myelopathy due to a neurocytoma of the upper thoracic spinal cord. The literature on spinal neurocytoma and its relation to central neurocytoma are discussed.

Mobilization of patients after spinal surgery for acute spinal cord injury.

STUDY DESIGN: A retrospective review was conducted covering records of patients who underwent spinal surgery after acute spinal cord injury. OBJECTIVE: To study the relation between time of operation and mobilization of patients. SUMMARY OF BACKGROUND DATA: No such report has existed in the literature. METHODS: Reviews were conducted for the medical records of 102 consecutive patients with acute spinal cord injury admitted to the National Spinal Injuries Center whose spines had been stabilized surgically. The surgeries had been performed either in the National Spinal Injuries Center or in hospitals of the United Kingdom or Continental Europe not specialized in comprehensive care of spinal cord injury. For the patients in three groups, the date of operation and the date of mobilization were compared. The causes for delay in mobilization were identified. RESULTS: A trend of negative correlation was found between the mean number of days from injury to operation and the mean number of days from injury to mobilization. Conversely, a trend of positive correlation was found between the mean number of days from injury to admission or transfer to the National Spinal Injuries Center and the mean number of days from injury to mobilization. Long stay in bed was associated with complications. None of the patients in Group A stayed in bed longer than 77 days, whereas 13 patients in Groups B and C combined had a longer stay. The difference was statistically significant (P = 0.02, chi2). Eight of these patients had pressure sores. CONCLUSION: To ensure early mobilization, early spinal surgery must be supported by specialized comprehensive care.

Implants for spasticity.

In carefully selected groups of patients, intrathecal baclofen therapy offers well-proven benefits in reducing spasticity, notably in cases of spinal injury and multiple sclerosis. The initial costs of implantation are high, and there must be a long-term commitment by both patient and medical personnel to careful and proper management. Nevertheless, in suitable cases, the techniques should generally be properly considered before proceeding to any irreversible destructive neurosurgical procedure.

Cerebrospinal fluid kinetics of epidural clonidine in man.

Ten patients with deafferentation pain after spinal cord injury were given 150 micrograms clonidine epidurally. CSF and plasma samples were collected over the following 24 h, and drug concentrations were measured by radio-immunoassay. The results of only 6 patients are included in the pharmacokinetic analysis because the catheters were not in the epidural space in the remaining 4 patients. These analyses revealed a mean maximum CSF concentration of 228 ng/ml whereas the mean plasma concentration at all time points was less than 0.7 ng/ml. The elimination half-life of epidural clonidine was 66 +/- 2 min, while the absorption half-life was 31 +/- 7 min, Tmax was 60 +/- 7 min and Cmax was 228 +/- 56 ng/ml. The ratio of the area under the curve (AUC) for CSF and plasma was 52. One patient's catheter was intrathecal and 3 were not in the epidural space. The measured plasma concentrations were similar after all injections. As 4 of 6 patients with epidural catheters obtained pain relief and all 3 patients with spasms obtained relief from epidural clonidine, these data suggest that clonidine has a place in the treatment of patients with spinal cord injury.

Supratentorial masses: stereotactic or freehand biopsy?

CT-guided stereotactic biopsy is now an accepted method of tissue sampling in intracranial mass lesions but many surgeons still practise freehand burrhole biopsy. This study compares two groups of patients who had either stereotactically guided (n = 153) or freehand (n = 217) biopsy. Stereotactic biopsy has a lower incidence of both mortality (2.6%) and morbidity (1.3%) than freehand (7.8 and 7.8%) while diagnostic accuracy is 92.1 and 64.9%, respectively. The success rate for stereotactic biopsy is independent of the size and depth of the lesion while freehand biopsy is most successful for large, superficial lesions but its success never exceeds 88%. The stereotactic technique is superior to the freehand for all intracranial biopsies regardless of size or site.

Total removal of craniopharyngiomas. Approaches and long-term results in 144 patients.

The clinical features, perioperative course, and postoperative outcomes of 144 patients who underwent microsurgical resection of craniopharyngioma were reviewed. Overall, 90% of the tumors were completely resected and 7% recurred. Evaluation of those patients who underwent primary resection revealed much better results. The operative techniques and approaches are reviewed in detail. The results of this series suggest that primary total removal of craniopharyngiomas yields the best long-term outcome for the patient. Experience has shown that the larger the tumor the greater will be the damage, both preoperatively and intraoperatively, to vital intracranial structures. Consequently, early diagnosis, at a stage when the tumor is still small, improves the chances of accomplishing complete removal and of achieving good operative results. The early diagnosis of craniopharyngioma, before it can produce devastating neurological defects, continues to be the principal goal of our medical and pediatric colleagues.

Effect of a new computed tomographic image transfer system on management of referrals to a regional neurosurgical service.

A computed tomographic image transfer system ('Image Link') was used to link scanners within the Oxford region, UK, to the regional neurosurgical service. 100 consecutive neurosurgical referrals were examined by this system; 43% of the emergency referrals did not require transfer, 31% were transferred electively, and 26% urgently. Most of the patients defined as potentially hazardous for transfer (10/11) did not require neurosurgical intervention. The delay by the use of the system was negligible and early detection of intracranial haematoma contributed to good outcome in some head injured patients. Overall, 3,170 miles of ambulance journey were avoided. Use of image link has led to substantial improvements in management of neurosurgical emergency referrals, cost-effectiveness of neurosurgical and ambulance facilities, and interhospital communication between doctors.

A double blind placebo controlled trial of the calcium entry blocking drug, nicardipine, in the treatment of vasospasm following severe head injury.

A double blind, placebo controlled trial of nicardipine in the treatment of high Doppler Flow Velocity (DFV) following severe head injury (Glasgow Coma Score (GSC) less than or equal to 8) was performed. Thirty patients with high DFV (greater than or equal to 100 cm/s for 6 h duration) on transcranial Doppler ultrasound, were treated with nicardipine or placebo for 24 h (2.5 mg/h, increasing in steps of 2.5 mg/h at 2 h intervals (maximum rate 7.5 mg/h) depending on response of DFV). DFV was measured hourly for 24 h and then every 12 h for 2 days. Nicardipine significantly reduced DFV below the threshold of 100 cm/s (16/19 cf placebo 3/11, chi-square p less than 0.001). In the nicardipine treated group maximum DFV was significantly reduced (p less than 0.001) and time with DFV below 100 was significantly longer. Rises in DFV were significantly reduced by the drug if the DFV was normal at the time of entry. High DFV returned on cessation of the infusion. No unexpected or adverse side effects were seen. No clinical benefit was demonstrable.

Metastasis of parotid acinic cell carcinoma to an internal carotid aneurysm: a case report.

Tumours related to intracranial aneurysms are rare. The authors report the metastasis of a parotid acinic cell carcinoma which spread to an intracavernous carotid aneurysm in a 51-year-old female. The tumour and aneurysm were partially excised at craniotomy with relief of the patients presenting headache.

Lymphomatoid granulomatosis apparently confined to one temporal lobe. Case report.

Lymphomatoid granulomatosis is of uncertain etiology and poses problems with diagnosis and treatment. A case with involvement of the right temporal lobe, but associated with cystoid macular edema of the retina, is described. The unusual mode of presentation, the radiographic, operative, and pathological findings, the response to surgery and radiotherapy, and the possible etiology are discussed.

Cerebral arterial vasospasm following severe head injury: a transcranial Doppler study.

Transcranial Doppler ultrasound was used to determine the natural history of cerebral arterial vascular spasm following severe head injury. Doppler Flow Velocity (DFV) was measured in the anterior cerebral, middle cerebral and terminal carotid arteries. High DFVs consistent with vasospasm were identified in 68% of the 25 patients studied. They came on from between 12 h and 4 days and lasted from 12 h to 14 days. No relationship could be determined between presumed vasospasm and blood pressure, intracranial pressure or outcome. Rises in the maximum DFV value (to above 100 cm s-1) were associated with neurological deterioration in 12 instances (in 11 of these the DFV remained elevated for more than 12 h). Deterioration occurred in three instances without change in DFV. DFV rose to above 100 cm s-1 on 10 occasions without neurological change (but remained elevated for more than 12 h in only four of these). Vasospasm has been found to be more common following head injury and may be a more significant cause of deterioration than previously thought.