Rheumatoid arthritis of the cervical spine. A long-term analysis with predictors of paralysis and recovery.

We analyzed the cases of seventy-three patients who were managed over a twenty-year period for rheumatoid involvement of the cervical spine and were followed for a minimum of two years, with an average follow-up of seven years. A neurological deficit did not develop in thirty-one patients (Ranawat et al. Class I) and paralysis developed in the remaining forty-two patients: Class II in eleven and Class III in thirty-one. Of the forty-two patients in whom paralysis developed, thirty-five had operative stabilization. Seven patients were managed with a soft cervical collar because they refused or were medically unable to have the operation; all of the had an increase in the severity of the paralysis. The posterior atlanto-odontoid interval and the diameter of the subaxial sagittal canal measured on the cervical radiographs demonstrated statistically significant correlations with the presence and severity of paralysis. All of the patients who had a Class-III neurological deficit had a posterior atlanto-odontoid interval or diameter of the subaxial canal that was less than fourteen millimeters. In contrast, the anterior atlanto-odontoid interval, which has traditionally been reported, did not correlate with paralysis. The prognosis for neurological recovery following the operation was not affected by the duration of the paralysis but was influenced by the severity of the paralysis at the time of the operation. The most important predictor of the potential for neurological recovery after the operation was the preoperative posterior atlanto-odontoid interval. In patients who had paralysis due to atlanto-axial subluxation, no recovery occurred if the posterior atlanto-odontoid interval was less than ten millimeters, whereas recovery of at least one neurological class always occurred when the posterior atlanto-odontoid interval was at least ten millimeters. If basilar invagination was superimposed, clinically important neurological recovery occurred only when the posterior atlanto-odontoid interval was at least thirteen millimeters. All patients who had paralysis and a posterior atlanto-odontoid interval or diameter of the subaxial canal of fourteen millimeters had complete motor recovery after the operation. In this series, although only patients who had a neurological deficit were operated on, we observed the range of the posterior atlanto-odontoid interval that was associated with poor or no recovery after the operation, and we identified the safe range on the basis of the patients in whom paralysis did not develop.(ABSTRACT TRUNCATED AT 400 WORDS)

Experimental lumbar spinal stenosis. Analysis of the cortical evoked potentials, microvasculature, and histopathology.

An animal model of lumbar spinal stenosis was developed in which the pathophysiology of this condition could be examined. Four experimental groups, each containing six dogs, were studied. One group had a laminectomy of the sixth and seventh lumbar vertebrae only; these animals served as controls. In the three other groups, a laminectomy was performed and the cauda equina was constricted by 25, 50, or 75 per cent to produce chronic compression. Cortical evoked potentials were recorded preoperatively, immediately after constriction, and at one, two, and three months postoperatively. Daily neurological examinations were carried out, and the neurological deficits were graded using the Tarlov system. After three months of constriction, the cauda equina of three dogs in each group was examined histologically, and the vascular circulation was examined by latex and India-ink injection with a modification of the Spalteholz technique. The animals in the control group showed no neurological abnormalities, no changes in cortical evoked potentials, normal microvascularity, and no histopathological changes in the nerve roots or the spinal cord. The dogs in which the cauda equina had been constricted 25 per cent had no neurological deficits, mild changes in cortical evoked potentials, slight histological changes, and venous congestion of the root and dorsal root ganglion of the seventh lumbar nerve. The dogs in which the cauda equina had been constricted 50 per cent had mild initial motor weakness, major changes in cortical evoked potentials, edema and loss of myelin in the root of the seventh lumbar nerve, and moderate or severe venous congestion of the root and dorsal root ganglion of the seventh lumbar nerve. The dogs in which the cauda equina had been constricted 75 per cent had significant weakness, paralysis of the tail, and urinary incontinence; two dogs recovered by the third month, but all had neurogenic claudication for three months. All six dogs had dramatic changes in cortical evoked potentials and had complete nerve-root atrophy at the level of the constriction. There was blockage of axoplasmic flow and wallerian degeneration of the motor nerve roots distal to the constriction and of the sensory roots proximal to the constriction, as well as degeneration of the posterior column. Severe arterial narrowing at the level of the constriction and venous congestion of the roots and dorsal root ganglia of the seventh lumbar and first sacral nerves were also present. Cortical evoked potentials revealed neurological abnormalities before the appearance of neurological signs and symptoms.(ABSTRACT TRUNCATED AT 400 WORDS)

Concurrent lumbar spinal stenosis and peripheral vascular disease. A report of nine patients.

Intermittent claudication from peripheral vascular disease is sometimes difficult to distinguish from neurogenic claudication secondary to lumbar spinal stenosis. Of 172 patients with symptoms of claudication and lumbar spinal stenosis proved by myelography or computed tomography (CT), nine had peripheral vascular disease identified with ultrasonography and arteriography. All of the nine patients had a laminectomy performed to decompress the narrow spinal canal, and two had an additional posterolateral fusion. Two patients were treated with an excision of their abdominal aortic aneurysm, while one of those patients later required a bypass graft for iliac stenosis. One patient had had an aortofemoral bypass graft, one a femoropopliteal graft, and one a lumbar sympathectomy. Follow-up study ranged from three to eight years, with an average of five years after their last surgical procedure. Paresthesias generally dissipated after the spinal surgery. The cramping-type discomfort associated with walking was not easily attributed either to vascular or a neurogenic etiology. Five patients had initial weakness, which invariably improved. A secondary etiology contributing to claudication must be excluded in those patients with persistent discomfort following previous lumbar spinal or vascular surgery for arterial insufficiency.

Pyogenic osteomyelitis of the occiput, the atlas, and the axis. A report of five cases.

Pyogenic osteomyelitis rarely affects the first and second cervical vertebrae, and when it does it can progress to abscess formation, compressing the spinal cord. If the process is unrecognized, it can be fatal. The cases of five patients are reported. Two patients were treated by anterior débridement and posterior cervical-occipital arthrodesis; one, by transoral drainage; one, by posterior cervical-occipital arthrodesis; and the fifth, by posterior atlanto-axial arthrodesis. The causative organism was Staphylococcus aureus in four patients and Pasteurella multocida in one. In all patients, intravenous antibiotics were used, followed by prolonged administration of oral antibiotics. All five patients recovered.

Treatment of the congenital vertical talus: a retrospective review of 36 feet with long-term follow-up.

To ascertain whether one type of treatment of the congenital vertical talus was superior to others, we conducted a retrospective analysis of 36 congenital vertical tali in 21 patients whose average follow-up of 14 years was considered to be unusually lengthy. Ten patients (48%) had an underlying primary diagnosis, and 13 patients (62%) had at least one other secondary congenital abnormality. None of the surgical techniques produced significantly better results than any other one according to criteria involving shoewear, range of motion, and degree of pain. Subtalar and talotibial motion were frequently restricted, with or without prior arthrodesis. Pain generally was not an immediate or long-term problem. To maintain maximal foot mobility, we recommend a one-stage soft tissue correction alone in the child under 3 years of age. In older, untreated children or those in whom conservative treatments have failed, a subtalar or triple arthrodesis may be necessary.

Internal hemipelvectomy and reconstruction for malignant primary acetabular tumors. A report of five cases.

Five patients underwent hemipelvectomy and reconstruction for the treatment of a primary malignant tumor involving the acetabulum. There were no intraoperative complications and only one postoperative complication. All patients were ambulating within one week of surgery. During the follow up period which averaged 4 years, all patients remained ambulatory and pain-free, and none showed radiographic evidence of loosening or subsidence of the prosthesis or pins.

The treatment of mucous cysts: long-term follow-up in sixty-two cases.

To determine the course of the so-called mucous cyst both after various modalities of treatment and without treatment, 56 patients with 62 cysts were contacted to participate in a study with an average follow-up of 6.2 years after initial evaluation. The mucous cysts primarily occurred in elderly women and were most prevalent in the index and long fingers. Longitudinal grooving of the nail was not uncommon and may hve preceded the appearance of the cyst. Degeneration of the distal interphalangeal joint was frequently found. The long-term results after treatment with simple aspiration or decapping, or by excision with skin grafts and flaps as needed or with observation only were similar. However, surgical excision or aspiration may eliminate earlier the cosmetic disfigurement and occasional discomfort that are associated with this lesion.