Safety and efficacy of epidural analgesia in spine surgery.

Over the last 4 years, the authors have had experience with epidural analgesia for a variety of spinal operations in 24 patients. It has proved to be safe, reliable, and effective. No patient has had a new neurological deficit as a result of the epidural technique, and 18 of 22 patients with neurological deficit improved. Thus, epidural analgesia should not be excluded from the anesthesiologist's consideration simply because of the presence of spine disease or neurological deficit.

Quantitative anatomy of the thoracolumbar epidural space.

Quantitative measurements of the epidural space between T-7 and L-4 were made in the sagittal and coronal planes utilizing x-ray films made after the injection of iodized oil into the epidural space in the low thoracic and upper lumbar areas. These data reveal a 1-mm ventral epidural space and a 2-mm lateral epidural space, with a sawtooth shape to the dorsal epidural space measuring between 1.1 and 2.9 mm at the rostral lamina and between 3.8 and 6.5 mm at the caudal lamina. Additionally, five patients with chronic pain were studied by computed tomography of T-8 to T-12, with confirmation of the sawtooth shape of the dorsal epidural space. Computed tomography showed the measurements of the epidural space at the rostral lamina to vary between 1.3 and 1.6 mm and those at the caudal lamina/interlaminar space to range from 6.9 to 9.1 mm.

The colchicine experimental epileptic focus: an intracellular study.

A new experimental epileptic focus is described in which colchicine is topically applied to neocortex. Stable epileptiform discharges developed, with bursts of action potentials, coincident with the surface epileptiform events. There were depolarizing and hyperpolarizing neuronal potentials and glial depolarizations concomitantly with the surface epileptic spikes.

Intraventricular pneumocephalus secondary to subcutaneous emphysema: a case report.

Intraventricular tension pneumocephalus is an unusual complication of surgically treated hydrocephalus. This is a life-threatening complication requiring prompt diagnosis and treatment. A case is presented wherein tension pneumocephalus developed as a result of cervicocranial subcutaneous emphysema in the presence of a ventriculoperitoneal shunt.

Scarring around cervical epidural stimulating electrode.

Scarring around the electrically stimulating electrodes has been of concern since dorsal column stimulation was introduced. This concern resurfaced in the days of cerebellar electrodes and, with the advent of epidural stimulating techniques for the control of pain and spasticity, it again arises as a potential problem. We present a patient who underwent the placement of a C-2-C-4 electrode to treat torticollis; 3 months later, a mild spastic quadriparesis developed and the stimulation became ineffective. At reexploration, dense scar surrounded the electrode and confined the cervical spinal cord. With microdissection techniques, the scar was removed from the dura mater and the dura began to pulsate freely. The quadriparesis reversed. Examination of the scar tissue microscopically showed linearly arrayed fibroblastic nuclei, and we are uncertain whether the exuberant fibroblastic response is a response to electrical stimulation, the materials used in the electrode, or some technical aspects of the operation.

Amphotericin B and imidazole therapy for coccidioidal meningitis in children.

Coccidioidal meningitis is a fatal form of Coccidioides immitis infection. Amphotericin B (AMB) therapy has reduced mortality but is itself toxic, and experience with it in very young children is meager. We are treating six children for coccidioidal meningitis diagnosed at 19 to 74 months of age. All had acute hydrocephalus and ventriculitis. The first four patients were initially treated with AMB but were changed to imidazole therapy (miconazole and ketoconazole). In the last two patients therapy was begun with the imidazoles. Ommaya reservoirs for cisternal therapy have been of limited usefulness. AMB therapy has been limited by local and systemic toxicity and by failure in one case. All children have improved with 15 to 22 mg oral ketoconazole per kg per day and 3 to 5 mg intraventricular miconazole for instillation therapy, including those with noncommunicating hydrocephalus in whom the intraventricular drug does not reach the basilar cisterns. Peak concentrations of ketoconazole in ventricular fluid were 0.08 to 5.6 micrograms/ml. Shunt obstruction and bacterial superinfections have been the major causes of morbidity. Imidazole therapy of coccidioidal meningitis may be more effective than is AMB in young children, and it offers the advantages of fewer side effects and not requiring intrathecal or cisternal administration.

Ultrasonic evaluation of postventricular shunt dynamics in infants and young children.

Two-dimensional echoencephalography provides a noninvasive method of monitoring the response of hydrocephalus to shunting in young children and of detecting complications of shunting. In this study an average of 74% of the decrease of ventricular size seen within the first six postoperative days had occurred by the first postoperative day. An average of 49% of the eventual decrease in ventriculography size occurred within the first postoperative week. The most helpful scans in the early postoperative period were obtained on the first postoperative day and again in the latter half of the first week. A clear departure from the usual pattern may indicate children at particular risk for significant shunt-related problems. While shunt failure was the most common complication, others such as mantle collapse with subdural hygromas, subgaleal fluid collections, loculations secondary to fibrous adhesions, and arachnoid cysts can be clearly defined.

Lumbar monoradiculopathy due to unilateral facet hypertrophy.

Twenty-two patients presented during the last 3 years with unilateral symptoms and signs of a lumbar monoradiculopathy indistinguishable from those of a disc herniation. All had compression of the nerve root posteriorly by a hypertrophic facet without anterior compression from the disc. None of the patients had spinal claudication. Preoperative evaluation with computed tomographic (CT) scanning was disappointing as the pathology was correctly defined in only 1 of 10 patients. Lumbar myelography was helpful, but did not always localize the lesion. The decision to operate was based primarily on the clinical grounds of persistent or progressive radiculopathy. The operative techniques used were two-level hemilaminectomy in 7 patients, single level laminectomy in 4, and multilevel laminectomy in 11. Surgical exploration revealed that the site of compression ranged from the medial canal to the lateral recess. The root was compressed by inferior facets 8 times and by superior facets 14 times. Back pain was relieved in 12 of 15 patients, and leg pain was relieved in 19 of 21. Neurological deficit was relieved in 19 and improved in 3. It is concluded that standard CT and myelographic techniques may not anatomically define the point of radicular compression. Intraoperatively the root must be explored from its dural origin to a point beyond the pedicle to ensure adequate decompression. Most, but not all patients with hypertrophic radicular compression will improve after surgical decompression.

Trapped fourth ventricle in coccidioidal meningitis.

A 4-year-old girl with known coccidioidal meningitis developed posterior fossa signs. CT scanning revealed a large fourth ventricle. Injection of contrast medium into the lateral ventricles revealed free flow into the fourth ventricle, and injection into the fourth ventricle revealed no flow into the aqueduct or third ventricle. The posterior fossa signs cleared after shunting of the fourth ventricle. A one-way aqueductal valve resulting from the ventricular inflammation is hypothesized.

Jejunoileal bypass: a reversible cause of dementia.

Neurological complications consisting of recent memory loss, visuospatial disorientation, and poor concentration disabled three patients years after a jejunoileal bypass for morbid obesity. The metabolic evaluation and computed tomography gave normal results. The neurological dysfunction cleared completely after reconstitution of normal intestinal anatomy. Neurological recovery was documented by formal neuropsychological testing.

Combined neurosurgical-otolaryngologic operative approach to a massive nasoethmoidal encephalomeningocele.

Frontal encephaloceles are uncommon yet challenging therapeutic problems that require careful planning and cooperation between the disciplines of neurosurgery and head and neck surgery. A case presentation is discussed together with the embryology, differential diagnosis, and surgical approach to the problem.

Intracellular records from chronic alumina epileptogenic foci in the monkey.

Neuronal records from the primate alumina focus revealed synaptic potentials with bursts of action potentials occurring on depolarizing potentials. These depolarizing potentials were not synchronous with electrocorticographic epileptic patterns. The configuration of the membrane potential changes was consistent with a dendritic generator for epileptic bursts. It is proposed that the genesis of these depolarizing potentials is postsynaptic.

Bleeding patterns from ruptured intracranial aneurysms: an autopsy series of 205 patients.

The autopsy records from 205 patients who died from ruptured intracranial aneurysms were reviewed. Special emphasis was placed on the cause of death and the time after rupture that death occurred. One hundred and sixty-eight patients (82%) died within one week of their last aneurysmal rupture. Eighty-eight died within one week of their initial rupture. Massive subarachnoid hemorrhage was the cause of death in 53% and localized hematomas in 14%. Eighty patients died within one week following a subsequent rupture. Intracranial hematoma was the cause of death in 87%, with 31% harboring a localized mass potentially amenable to surgical therapy.

Postpartum acute subdural hematoma; a probable complication of saddle block analgesia.

The author present a patient who developed an acute intracranial subdural hematoma approximately 35 hours after an uncomplicated delivery under saddle block analgesia. The proposed mechanism is that of cerebrospinal fluid efflux through the lumbar puncture site during uterine contractions and straining; shift of the intracranial structures, especially veins; venous hypertension; venous rupture; and subdural hematoma formation.