Aizik L. Wolf

Complete temporal lobectomy for surgical resuscitation of patients with transtentorial herniation secondary to unilateral hemisphearic swelling.

Transtentorial herniation is an ominous finding in the patient with head injuries. We report our experience with 10 patients suffering from acute transtentorial herniation secondary to posttraumatic unilateral hemispheric swelling who were treated aggressively with temporal lobectomy. Eight patients were men and 2 were women. Their ages ranged from 22 to 61 years, with a mean of 37 years. Their preoperative Glasgow Coma Scale scores ranged from 3 to 6, with a mean of 4. All patients had both computed tomographic and clinical evidence of unilateral hemispheric shift and acute herniation without a significant subdural or epidural hematoma. Seven patients had unilateral nonreactive pupils and 3 had bilateral nonreactive pupils. All were taken to the operating room within 2 hours of clinical signs of herniation. Complete unilateral temporal lobectomies including the mesial structures, amygdala, and uncus were performed. In this series, the mortality rate was 30%, including a single patient who was neurologically stable but died from nonneurological injuries. Of the 7 survivors, 4 were functionally independent and 3 required minimal assistance with the activities of daily living. Aggressive, early decompression via complete temporal lobectomy may thus significantly improve the outcome in patients with transtentorial herniation accompanying posttraumatic hemispheric swelling and midline shift.

Fractures of the clivus: classification and clinical features.

Fractures of the clival complex were diagnosed in a series of 17 patients admitted to the Maryland Institute for Emergency Medical Services System and the University of Maryland Medical System over a 30-month period. These fractures were divided pathologically into three types based upon their appearance on computed tomography: longitudinal, transverse, and oblique. The mechanisms of injury were similar in all groups, and the Glasgow Coma Scale scores at admission were comparable, regardless of fracture type, in survivors and nonsurvivors. Longitudinal fractures were associated with severe injury to the central nervous system and with brain stem infarction, and 4 of 6 (67%) of these patients died. Transverse fractures of the clival complex were found in 6 patients, 3 of whom (50%) died. All of these patients had fractures of the petrous ridge; 2 of the 3 survivors had multiple cranial nerve deficits, and one patient developed a carotid-cavernous fistula. Of the 5 patients with oblique clival fractures, 2 survived (40%), both of whom had multiple cranial nerve palsies; in addition, one of these patients developed a carotid-cavernous fistula. Using the present generation of computed tomographic scanners, fractures of the clival complex can be reliably diagnosed; they are probably more common than previously believed and can be separated into three groups based on the characteristics on computed tomographic scans and clinical findings.

Posterior spinal osteosynthesis for cervical fracture/dislocation using a flexible multistrand cable system: technical note

Cervical instability secondary to fracture/dislocation or traumatic subluxation involving the posterior elements may be treated by a variety of fusion techniques. The rigidity of the stainless steel wires used in posterior cervical fusions often leads to difficulty with insertion, adequate tension, and conformation of the graft construct. This report describes a technique of posterior cervical fusion employing a wire system using flexible stainless steel cables. The wire consists of a flexible, 49-strand, stainless steel cable connected on one end to a short, malleable, blunt leader with the opposite end connected to a small islet. The cable may be used in occipitocervical, atlantoaxial, facet-to-spinous process, and interspinous fusion techniques. The cable loop is secured by using a tension/crimper device that sets the desired tension in the cable. In addition to superior biomechanical strength, the flexibility of the cable allows greater ease of insertion and tension adjustment. In terms of direct operative instrumentation in posterior cervical arthrodesis, involving both the upper and lower cervical spine, the cable system appears to be a safe and efficient alternative to monofilament wires.

Melanoma Arising in a Cervical Spinal Nerve Root: Report of a Case with a Benign Course and Malignant Features

A 20-year-old caucasian woman with a 5-year history of right arm, neck, and back pain sought treatment when an automobile accident (4 months before admission) exacerbated her pain. Magnetic resonance imaging revealed an intra- and extradural mass compressing the spinal cord at the C5-C6 level. It also extended into and widened the neural foramen, mimicking a neurofibroma. A single cafe-au-lait spot was discovered in the inguinal region. A two-staged surgical resection was performed on an apparent hemorrhagic C6 nerve root mass. The mass exhibited diagnostic features of a malignant melanoma histologically, immunocytochemically, and ultrastructurally. A search for a primary lesion outside the nervous system or other metastases during an 8-year period from the onset of symptoms has been negative. The patients chronic history, evidence of neural foraminal enlargement, and the absence of other malignant melanoma lesions or subsequent metastases indicates that this lesion may be a primary melanoma of the nerve root with a benign course.

Diastematomyelia of the Cervical Spinal Cord with Tethering in an Adult

A case of cervical diastematomyelia associated with spinal cord tethering in an adult is presented. The differences between cervicodorsal and lumbar region spinal dysraphic states are emphasized with a review of the embryological factors involved. Possible causes and subsequent treatment are outlined.

Choriocarcinoma with brain metastases. Successful management of increased intracranial pressure with barbiturates

Choriocarcinoma is a potentially curable neoplasm. Although the presence of intracranial metastases worsens the ultimate prognosis, several reports have shown successful response to therapy. This clinical report outlines a method by which the appropriate therapy may be initiated in a patient with intracranial metastases, who otherwise may not have survived the interval necessary for the induction of successful therapy.

Bodysurfing Accidents Resulting in Cervical Spinal Injuries

During the summers of 1987 and 1988, 14 cervical spine injuries sustained during bodysurfing accidents at the beaches around Ocean City, Maryland presented to our Neurotrauma service. All the patients were men, predominantly in their middle years (mean age=40), and otherwise healthy. Likely mechanisms of injury suggested by radiography and computed tomography-myelography included hyperflexion, hyperextension, and axial loading. Clinically, neurologic deficits were found in 10 patients (71%), of whom 2 were complete sensorimotor quadriplegics below the level of injury, and 8 were incomplete injuries. Of the eight incomplete injuries, two-thirds were central cord syndromes associated with narrow spinal canals and prominent osteophytes, and one-third had Brown-Sequard or anterior cord syndromes. After initial anatomic realignment by closed or open reduction, the injured cervical spines were stabilized either externally or internally. Two patients underwent laminectomies. These bodysurfing accidents, in marked contrast to other types of shallow water-diving accidents, predominantly involved older men and produced incomplete injuries. It is concluded that bodysurfing is peculiarly hazardous to healthy, middle-aged men, especially those endowed with a narrow spinal canal with or without osteophyte formation.

Myelographic and enhanced computed tomographic appearance of acute traumatic spinal cord avulsion

The neuroradiological findings that revealed spinal cord transection/laceration in 6 patients with acute, blunt spinal trauma are described. Four patients suffered cervical spine injuries, and two had thoracic injuries. Initially, all patients had complete neurological deficit at the level of injury. The deficit improved in only 1 patient. On the basis of clinical history and spinal radiographs, spinal hyperflexion with distraction was the predominant mechanism of injury in our patients. Computed tomography with intrathecal contrast was performed on all patients and was always diagnostic. Visualization of intrathecal contrast material accumulating within the cord or the absence of cord shadow within the contrast column established the diagnosis in all cases. A dural tear was noted in 3 patients. Thoracic myelography was performed in 2 patients and, in both, demonstrated contrast pooling within the spinal cord at the level of the laceration. Magnetic resonance imaging was obtained in 1 patient and revealed an irregular, low-signal-intensity, intramedullary region extending to the cord surface on T1-weighted axial images. The myelographic and enhanced computed tomographic appearances of acute, traumatic spinal cord avulsion/laceration, which have been infrequently reported in the literature, are described.