Is the efficacy of the Cloward procedure overestimated? Technique of evaluation affects the outcome.

The purpose of the present study was to investigate the influence of the evaluation technique on the outcome of the Cloward procedure in cervical radiculopathy. The retrospective study included 94 consecutive patients operated on with anterior decompression and fusion with heterologous bone (Surgibone, Unilab). There were 56 men and 38 women, with a mean age of 48 years (range 27-78 years). Sixty-six patients had a single-level fusion, 26 a two-level fusion and one patient had a three-level fusion. The follow-up rate was 91/94 (97%) and evaluation was performed by an independent observer. Pain was quantified by visual analogue scale (VAS, range 0-100), functional disability by the new functional index Cervical Spine Functional Score (CSFS, range 0-100) and by the Neck Pain Disability Index (NPDI, range 0-100). The overall clinical outcome was assessed as excellent, good, fair or poor by both the patient and by the independent observer using Odom's criteria. At a mean follow-up of 26 months (range 12-56 months) the mean pain index was 39 (range 0-98), the mean CSFS 39 (range 0-85) and the mean NPDI 32 (range 0-76). The classification of the observer was 37% excellent, 40% good, 17% fair and 6% poor, and that of the patient was 53% excellent, 23% good, 20% fair and 4% poor. In the group classified as good by the observer, all scores were above 40, suggesting considerable remaining symptoms, and only 50% had returned to work. The results suggest that previous reports on the Cloward procedure using categorizations into excellent, good, fair or poor have overestimated the efficacy of the procedure. Only an excellent, but not a good, result as classified by the patient or an independent observer reflects a successful outcome. Neither of the variables studied seems independently sufficient for a balanced reflection of the outcome. The results suggest pain (VAS) as the primary outcome measurement, which, combined with the overall evaluation by the independent observer and work status, gives a multidimensional expression of the outcome.

Degenerative changes following anterior cervical discectomy and fusion evaluated by fast spin-echo MR imaging.

PURPOSE: To review pre- and postoperative fast spin-echo (FSE) MR images of disc herniation and spondylosis in patients after spinal cervical surgery. MATERIAL AND METHODS: Data were reviewed of 68 patients after anterior discectomy and fusion (ADF) operations using the Cloward technique with solid single level (C5-C6 or C6-C7) or 2-level fusions (C5-C7). The average interval from surgery to review was 37 months. Age- and sex-matched controls without neck problems were examined. RESULTS: Preoperatively, the fusion groups had a higher incidence of protruded disc, and anterior and posterior osteophytes at the levels to be fused than the controls. Post-operatively, there was a significantly higher incidence of posterior osteophytes at the fused levels compared with the controls. Furthermore, the disc herniations and anterior osteophytes at the levels above and below the operated segments were more frequent in the fusion group. CONCLUSION: ADF causes acceleration of the degenerative changes at the fused level and at the levels below and above the fused segments.

Fast spin-echo MR assessment of patients with poor outcome following spinal cervical surgery.

PURPOSE: The aim of the investigation was to evaluate poor outcome following spinal and cervical surgery. MATERIAL AND METHODS: A total of 146 consecutive patients operated with anterior discectomy and fusion (ADF) with the Cloward technique were investigated. Clinical notes, plain radiography, CT, and fast spin-echo (FSE) images were retrospectively evaluated. RESULTS: Some 30% of the patients had unsatisfactory clinical results within 12 months after surgery; 13% had initial improvement followed by deterioration of the preoperative symptoms, while 14.4% were not improved or worsened. Disc herniation and bony stenosis above, below, or at the fused level were the most common findings. In 45% of patients, surgery failed to decompress the spinal canal. In only 4 patients was no cause of remaining myelopathy and/or radiculopathy found. FSE demonstrated a large variety of pathological findings in the patients with poor clinical outcome after ADF. Postoperatively, patients with good clinical outcome had a lower incidence of pathological changes. CONCLUSION: FSE is considered the primary imaging modality for the cervical spine. However, CT is a useful complement in the axial projection to visualize bone changes.

Significance of "ultra-early" rebleeding in subarachnoid hemorrhage.

Knowledge of the local incidence of aneurysm rupture permits the conclusion that almost every patient in the population of 933,800 persons served by the authors' institution who was stricken by this catastrophe and survived long enough to be transported was treated at this center (121 patients during 34 months). Of these, 9.1% were admitted late (greater than 72 hours after subarachnoid hemorrhage (SAH]; of the remaining cases, 94.5% were seen within 24 hours and 50% within 6 hours post-SAH. Of the 121 patients, 10% were neurologically devastated on arrival, a late operation was planned for 19%, and the earliest possible surgery and nimodipine administration was selected for 71%. In this latter group, 50% of the operations were begun within 24 hours and 76% within 48 hours post-SAH. Sixty percent of all mortality and morbidity could be linked to the initial aneurysm bleed. The remaining 40% could be ascribed to potentially avoidable causes of unfavorable outcome. No less than 9.6% of all patients admitted within 24 hours after SAH suffered from "ultra-early" rebleeding during transportation or preparation for operation. The mortality rate from such rebleeding was 7.4%, compared with the 9.1% combined mortality rate from complications and late ischemia.

Results of treatment for cerebral saccular aneurysms in a small neurosurgical unit--evaluation of early operation and nimodipine treatment.

91 patients in Hunt and Hess grade I to III directly after aneurysm rupture in the anterior circulation were treated by earliest possible surgery in conjunction with parenteral Nimodipine. 96% of the cases were seen in this centre within 24 hours from bleeding and surgery was commenced in 78% within 48 hours post haemorrhage. 8% suffered from "ultra early" rebleds six of which proved fatal. 12% of the cases had medical and surgical complications whereas only 3% had permanent late ischaemic sequelae. This low incidence of ischaemia may suggest a beneficial effect from Nimodipine treatment. The need for an aggressive surgical approach to aneurysms in order to minimize the omnious impact of rebleedings is stressed, although the importance of complications and technical misadventures must also be taken into consideration.

Local application of 133Xenon for measurement of regional cerebral blood flow (rCBF) during halothane, enflurane, and isoflurane anesthesia in humans.

It is well known that halothane causes an increase in cerebral blood flow (CBF). In this study the effects of halothane, enflurane, and isoflurane on regional cerebral blood flow (rCBF) in humans were determined in the presence of 70% N2O at a combined MAC concentration of 1.5. CBF was determined in 24 patients from the washout of locally applied 133Xenon with the use of an external scintillation. All 24 patients (control n = 6, halothane n = 6, enflurane n = 6, and isoflurane n = 6) were undergoing neurosurgical procedures. All patients were anesthetized with thiopental, fentanyl, droperidol, and 70% N2O in oxygen and paralyzed with pancuronium. The measurements were performed after the dura had been opened and before definitive surgery. The first measurement was done in the absence of any volatile agent, and the wash-out curve was registered for 6 min. The second measurement was done after one of the volatile agents had been added for at least 20 min and had reached a concentration of 0.58% for halothane, 1.14% for enflurane, or 1.0% for isoflurane in the expiratory gases in order to obtain about 1.5 MAC with each volatile anesthetic. The anesthetic concentrations were measured with the Engström multigas analyzer EMMA. The physiologic variables changed very little throughout the period of observation. Body temperature, heart rate, blood pressure, PaCO2, and PaO2 were stable. Ephedrine was used to maintain a stable arterial pressure. At approximately 1.5 MAC, halothane (plus N2O) increased rCBF to nearly three times (166%) the control value, while enflurane induced only a slight increase (35%) in rCBF.(ABSTRACT TRUNCATED AT 250 WORDS)

Locally applied 133Xenon for the measurement of regional cerebral blood flow (rCBF): an experimental study in the pig.

A method for measuring regional cerebral blood flow has been developed. On pig brain cortex a 1 cm2 size polyester film was placed, under which 0.6-1.3 mCi of 133Xenon in 2-4 microliter of saline was applied atraumatically. The wash-out process was registered with an external detector, and can be described as a sum of monoexponential functions. The first component of the curve, obtained by curve resolution, indicates blood flow in grey matter and the second slow component indicates blood flow in white matter. When total ischaemia was induced, there was no wash-out of the isotope. Freezing the brain after isotope application at different stages during the wash-out showed isotope in both grey and white matter. The isotope did not diffuse into the polyester film. This technique was also used in studies on the spinal medulla where white matter is outermost and grey innermost. The wash-out curve obtained consisted of only one monoexponential function; blood flow from grey matter was not present in the wash-out curve. For calculation of cerebral blood flow a modified two-compartment model was used. It is concluded that this method measures local cerebral blood flow in both grey and white matter. The method can be used clinically to measure the local cerebral blood flow during neurosurgical operations.

Internal neurolysis or ligament division only in carpal tunnel syndrome--results of a randomized study.

In a series of patients with clinically and neurophysiologically well defined carpal tunnel syndrome a randomization has been made into two groups, one for operation with internal neurolysis and a microscopical technique, and the other group for cutting of the carpal ligament (flexor retinaculum) alone. The two groups have been compared postoperatively regarding clinical and neurophysiological parameters. All patients improved, 89% in both groups considered themselves totally free of symptoms at follow-up examinations but there was no significant difference in any parameter between the two groups. As a conclusion the use of internal neurolysis cannot be recommended as a routine procedure in carpal tunnel syndrome.