Cervical discectomy. A prospective analysis of three operative techniques.

BACKGROUND: Cervical disc herniation causing neurological compromise is a common affliction. Sophisticated surgical treatments have been developed throughout the twentieth century and are largely successful. Although each procedure has its supporters, it is still unclear if one surgical technique is superior. METHODS: A prospective trial was designed to evaluate the efficacy of three surgical procedures for the treatment of cervical radiculopathy caused by a unilateral acute herniated cervical disc. Patients were randomized to posterior cervical foraminotomy (FOR), and anterior cervical discectomy with (ACDF), and without (ACD) fusion. Perioperative data, office follow-up and long-term follow-up were used to compare the procedures. RESULTS: All of the procedures yielded excellent relief of symptoms and signs postoperatively and during follow-up. Operative time and hospital stay were slightly shorter for ACD compared with ACDF and FOR. Reoperations occurred in all groups but there was a trend for higher recurrence at the same level with FOR and recurrence at other levels with ACDF. CONCLUSION: All three of the procedures were successful for treatment of cervical radiculopathy caused by a herniated cervical disc. Although the numbers in this study were small, none of the procedures could be considered superior to the others. This study suggests that the selection of surgical procedure may reasonably be based on the preference of the surgeon and tailored to the individual patient.

Anterior cervical discectomy: is fusion necessary?

OBJECT: A prospective, randomized trial was performed to compare the efficacy of anterior cervical discectomy (ACD) with ACD and fusion (ACDF) for the treatment of cervical spondylosis in patients with neurological compromise. METHODS: Forty-four patients underwent ACD and 40 underwent ACDF. Operative time and length of hospital stay were shorter and there was less need for analgesia in the ACD group. It was found that whereas the incidence of fusion was greater in the ACDF group compared to the ACD group (97 compared with 70%, respectively; p<0.01), patient satisfaction and a return to preoperative activity level was similar between groups. CONCLUSIONS: Analysis of the results suggests that the addition of a fusion procedure may be unnecessary.

Rupture of previously documented small asymptomatic saccular intracranial aneurysms. Report of three cases.

In a recent study from the Mayo Clinic on the natural history of intact saccular intracranial aneurysms, none of the aneurysms smaller than 10 mm in diameter ruptured. It was concluded that these aneurysms carry a negligible risk for future hemorrhage and that surgery for their repair could not be recommended. These findings and recommendations have been the subject of much controversy. The authors report three patients with previously documented asymptomatic intact saccular intracranial aneurysms smaller than 5 mm in diameter that subsequently ruptured. In Case 1, a 70-year-old man bled from a 4-mm middle cerebral artery aneurysm that had been discovered incidentally 2 1/2 years previously during evaluation of cerebral ischemic symptoms. A 10-mm internal carotid artery aneurysm and a contralateral 4-mm middle cerebral artery aneurysm had not ruptured. Case 2 was that of a 66-year-old woman who bled from a 4-mm pericallosal aneurysm that had been present 9 1/2 years previously when she suffered subarachnoid hemorrhage (SAH) from a 7 x 9-mm posterior inferior cerebellar artery aneurysm. Although the pericallosal aneurysm had not enlarged in the intervening years, a daughter aneurysm had developed. The third patient was a 45-year-old woman who bled from a 4- to 5-mm posterior inferior cerebellar artery aneurysm that had measured approximately 2 mm on an angiogram obtained 4 years previously; at that time she had suffered SAH due to rupture of a 5 x 12-mm posterior communicating artery aneurysm. These cases show that small asymptomatic intact saccular intracranial aneurysms are not innocuous and that careful consideration must be given to their surgical repair and long-term follow-up study.

Head injury at the southeastern Georgia Regional Trauma Center: a three-year review.

The impact of head injury on our trauma center is significant because of the large number of cases with their heavy utilization of trauma center resources. Head injury also exerts a major influence on the Trauma Center in a rural area since it serves as a major provider of care for the head injured over a wide geographical area. Mortality rates seen in this population compare favorably with contemporary data from other studies using GCS and Head AIS as indicators of level of injury.

Experience with the neodymium:yttrium-aluminum-garnet laser in forty-two cases.

The neodymium:yttrium-aluminum-garnet (Nd:YAG) laser has been utilized in the treatment of 42 cases during the past 2 years at two institutions. The laser was used under investigational permits from the Food and Drug Administration. It was found to be of particular value in the treatment of vascular intracranial tumors, especially meningiomas, and metastatic tumors of the spine. The ability of the laser to shrink and devascularize these tumors was efficacious as a surgical adjunct. Laser treatment of tumor attachments, especially those of meningiomas to the skull base, seemed to be effective in eradication of residual tumor. Long term benefits of such therapy, however, remain unproven. Because of the penetrating ability of the Nd:YAG laser beam, this device must be used with care by surgeons experienced in its use to prevent injury to adjacent structures.

Reversible somatosensory evoked potential changes with neodymium: yttrium-aluminum-garnet laser use.

Reversible prolongation and dissolution of the tibial somatosensory evoked potential (SEP) was observed with operative use of the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser during extirpation of a foramen magnum meningioma. Rapid normalization of the SEP followed irrigation with cool saline. The absence of postoperative dorsal column deficit suggests that heat-related physiological changes occurred before the point of irreversible tissue injury. Should intraoperative SEP monitoring prove a reliable index of tissue temperature, it could enable safer use of the Nd:YAG laser in the vicinity of the spinal cord and brain stem.

Surgical treatment of incidental intracranial aneurysms.

It is clear that more incidental aneurysms will be encountered in the future. Approximately 5% or more of the population harbors these lesions, and advancing technology can be expected to demonstrate them with increasing regularity. Multiple aneurysms will also be found in at least 18% of patients with subarachnoid hemorrhage due to aneurysms. The best estimates suggest a rate of hemorrhage approximating 1%/year for incidental aneurysms and a 0.4 to 0.65% annual mortality rate for these lesions. It has also been shown that even small aneurysms may enlarge and bleed unpredictably with the passage of time. Surgery for incidental aneurysms of the anterior circulation can be accomplished without mortality and with an operative morbidity of 6.5%. Higher morbidity occurs in surgery for aneurysms in more difficult locations as well as larger aneurysms. The increased risk of bleeding from larger aneurysms, however, may justify the increased morbidity of surgery for these lesions. Surgery for incidental aneurysms can be recommended in healthy individuals whose anesthetic risk is acceptable and for aneurysms less than 1.5 cm in diameter arising from the middle cerebral and posterior communicating arteries. Advancing age alone is not a contraindication for surgery, nor is size greater than 1.5 cm in diameter; however, the latter factor increases the operative risk. Operations to clip aneurysms of the carotid bifurcation, carotid-ophthalmic, and anterior communicating arteries may also be recommended, but these aneurysms are more difficult to approach and surgery carries a higher morbidity. Larger aneurysms, greater than 1.5 cm in diameter, in patients over 60 years of age, and in less accessible locations may not benefit from operation because surgical morbidity for these lesions is high and with advancing age the lifetime risk of rupture has decreased. For incidental aneurysms of the posterior circulation there are insufficient data to make a recommendation regarding surgery, although it is anticipated that the counsel for anterior circulation aneurysms will apply. If operative mortality and morbidity are to be maintained at acceptable levels, incidental aneurysm surgery should be the province of the accomplished aneurysm surgeon who has available to him the most modern techniques and equipment. With the clipping of incidental aneurysms, hopefully the number of patients suffering from subarachnoid hemorrhage with its high morbidity and mortality rates can be further reduced.

Surgical treatment of incidental intracranial aneurysms.

A 6-year retrospective analysis of incidental intracranial aneurysm surgery was conducted at 12 medical centers (1975-1981). The surgical facilities and techniques were comparable at the institutions surveyed. From a total of 1671 aneurysms operated upon, 119 in 107 patients were unruptured and were discovered incidentally. Among these 107 patients, there was no operative mortality. Operative morbidity occurred in 7 cases (6.5%). Surgical treatment of large aneurysms in less accessible locations incurred the greatest operative morbidity. Presenting symptoms of cerebral ischemia seemed to be associated with increased operative morbidity, whereas repair of aneurysms incidental to other ruptured aneurysms had a uniformly low morbidity. These surgical results compare favorably with the risks of hemorrhage from unruptured intracranial aneurysms as defined by recent reports. The low morbidity without mortality supports a recommendation for surgical management of incidental aneurysms in the anterior circulation at centers equipped for modern aneurysm surgery.

Atypical fibromuscular hyperplasia. Report of two cases.

Two cases of atypical fibromuscular hyperplasia of the internal carotid artery (ICA) are reported. These cases are unique because the changes involve the intima of the vessels without involvement of medial structures as seen in the more common form of fibromuscular hyperplasia. Case 1 is only the fourth report of a symptomatic fibromuscular stenosis at the origin of the ICA. Case 2 is the first report of fibromuscular hyperplasia involving the common carotid artery. Changes similar to those in Case 2 (an elongated area of tubular fibromuscular stenosis) have been reported in the ICA. These atypical or intimal forms of fibromuscular hyperplasia appear to be more common in males and blacks, and may be more often unilateral as well.

Ocular motor dysfunction in total and hemicerebellectomized monkeys.

Studies of ocular motor function in monkeys undergoing either total or hemicerebellectomies has revealed the following abnormalities which can be attributed to cerebellar dysfunction: 1. Loss of smooth pursuit movements 2. Gaze-fixation nystagmus 3. Loss of inhibitory input on the vestibular apparatus reflected in a decreased latency and prolonged response to caloric stimuli. It is intimated that the role of the hemicerebellum deals with ipsilateral tone and its effect on eye movements.