Bernard S. Epstein

NERVE ROOT COMPRESSION ASSOCIATED WITH NARROWING OF THE LUMBAR SPINAL CANAL

During a study of low back pain and radiculitis, certain patients were observed who did not conform to the criteria of the classical compression syndromes caused by osteophytes or herniated discs (Epstein, 1960). Symptoms and signs of nerve root compression were far more severe than could be explained by the presence of relatively minor intrusions. Pre-operative myelograms disclosed single and often multiple defects of varying extent, some with complete block suggesting the presence of lesions more extensive than were encountered at operation. A significant common finding in these patients was the difficult operative exposure of the interspace caused by unusually prominent, bulbous articular facets and thickened, vertically orientated laminae. The spinal canal itself was shallow and exploration within its narrow confines was remarkably restricted. It became apparent that liberal unroofing of the spinal canal over the course of the nerve roots was as important for relief of symptoms as the excision of disc protrusions and spurs. In reaching these conclusions, we were aided by previous experience in the management of a 15-year-old achondroplastic dwarf with compression of the conus and cauda equina by multiple lumbar intervertebral discs bulging into a congenitally narrowed spinal canal (Epstein and Malis, 1955). The deformities of the neural arches and the concomitant reduction in the width and depth of the spinal canal were similar in this patient and those of the present series. The protruding discs in the floor of the canal were left undisturbed, adequate relief being obtained by laminectomy alone. Gratifying restoration of function with relief of pain followed a decompressive laminectomy of the twelfth dorsal and of all the lumbar vertebrae, and there has been no recurrence of symptoms since January, 1954. Even a small herniated intervertebral disc in an achondroplastic dwarf may cause catastrephic trauma to the spinal cord and cauda equina because of the absence of available space for displacement of these structures within the narrow bony canal (Spillane, 1952; Schreiber and Rosenthal, 1952; Vogl and Osborne, 1949). A similar lack of space predisposes the patients in the present group to the untoward effects of neural compression by minimal intrusions.

Visualization of an Intracranial Arteriovenous Fistula during Angiocardiography in an Infant with Congestive Heart Failure

Congestive heart failure in infants resulting from congenital intracranial arteriovenous fistulas is infrequent. The case reported here is believed to be the first one in which an angiocardiogram done for the identification of a possible congenital cardiac malformation incidentally disclosed the vascular anomaly in the posterior cranial fossa because the lower half of the skull happened to be included in the radiographic field. Case Report J. E. S., an 11 week-old girl, had been delivered spontaneously. Her birth weight was 6 pounds 2 ounces. For the first six weeks of life she was apparently normal. She then became restless, dyspneic and cyanotic. A grade II systolic murmur was present, the liver was moderately enlarged, and peripheral edema was noted over the lower extremities. Radiographic examination of the chest disclosed diffuse cardiac enlargement. It is of interest that one of the nurses had noted a humming sound when her ear was held close to the patients head. On angiocardiographic examination ...

Vertebral Changes in Childhood Leukemia

The osseous changes produced by leukemia in children have long been recognized, the acute lymphatic form being the chief offender. Best known are the radiolucent transverse bands at the diaphyseal ends of the long bones, ascribed primarily to pressure effects of proliferating packed leukemic cells on actively growing bone. Other structural changes include focal destruction of cancellous and cortical bone, perforations of bone cortex, periosteal elevation, subperiosteal bone formation, diffuse osteoporosis, and occasionally osteosclerosis (1, 8). Extensive leukemic deposits may be present in the bone marrow with no visible effect. While in some cases osseous involvement may produce no discomfort, in others there may be pain which is readily confused with rheumatic symptoms. Spinal involvement in leukemia has not received as much attention as the better recognized changes in the extremities. Vertebral osteoporosis, compressional deformities, and occasional instances of bone destruction have been recorded (3...

Lap-sash three point seat belt fractures of the cervical spine

Cervical spine injuries associated with three-point fixation lap-sash seat belts result from Impact against the sash. While such injuries are infrequent and often without serious neurologic sequelae, they may produce serious deficits with grave injuries. Flexion-extension fractures of the lower cervical vertebrae, fractures of the transverse and spinous processes of the lower cervical and uppermost thoracic vertebrae, discal disruptions, and brachial plexus avulsions may occur. Of the 3 patients reported here, 2 escaped serious damage.

Subepicranial hydroma. A complication of head injuries in infants and children.

Summary The accumulation of spinal fluid beneath the epicranius as a soft, fluctuant mass is a complication of head injury with fracture in children. The swelling is nontender and is usually not associated with any significant evidence of brain injury. It appears within hours or days after the trauma, which usually is of the blunt type. Once apparent, the swelling may increase dramatically in size and, at times, envelop the entire hemicranium. A marginal rim is present in some of the more restricted collections, usually in the parietal region. Roentgenograms disclosed linear fractures in 80 per cent of the cases, which are most often in the parietal area and often cross a suture line. The duraarachnoidal tear occurs at the fracture line and permits the escape of cerebrospinal fluid into the subepicranial areolar tissue. The fluid is absorbed spontaneously; aspiration is contraindicated because of the possibility of introducing infection. No treatment is required.

Deformities of the skull surfaces in infancy and childhood

Summary The most common alterations in the surface of the skull in infants and children have been described. The various methods of diagnosis and management have been reviewed with emphasis on the manner of distinguishing those that have clinical significance from the larger numbers that are essentially innocuous. Lesions of the scalp must be differentiated from tumors or other mass lesions originating in the calvarium. Exacting roentgenographic study is mandatory.

Esophageal pressure pulse patterns (esophageal piezocardiogram)

Abstract It would appear from this study that one can determine the contour of the left atrial pressure pulse curve by recording esophageal pulsations at the level of the left atrium with the technique which has been described. This relationship between the intra-atrial pressure pulse contour and the contour of the esophageal pressure pulse tracing (piezocardiogram) has been demonstrated by two kinds of evidence. The first evidence consisted of a study in animals wherein simultaneous recordings were made of left atrial pressure curves and curves of esophageal pressure pulsations. These studies showed that all phases of the atrial pressure curve were transmitted to the esophageal curve. The second type of evidence consisted in a comparison between direct intra-atrial pressure tracings which had been obtained by other investigators in human beings with mitral valve disease and the esophageal piezocardiograms which had been obtained by us in other human beings who also had mitral valve disease. This evidence, though circumstantial in a sense, appeared to us to be strongly convincing. Absolutely conclusive proof in human beings of the identity between the two sets of curves could be obtained only by simultaneous recording of the direct atrial and esophageal pressure curves in the same individual during mitral valve surgery. We have not yet been able to accomplish this. On the basis of the comparative evidence discussed above, it was possible to tentatively divide the piezocardiographic tracings into three categories, namely, predominant mitral insufficiency, mitral stenosis without insufficiency, and mitral stenosis with insufficiency. Tracings of patients with mitral insufficiency were characterized by a positive pressure wave which began its ascent in ventricular systole, rose progressively, and reached a peak in late systole just prior to the opening of the mitral valve. The pressure then declined precipitously. This wave contour corresponded very closely to the findings of Wiggers 4, 5 in animals with experimentally induced mitral insufficiency. He emphasized that the increase in atrial pressure and volume due to regurgitation did not reach substantial proportions in the early phases of ventricular systole. The greatest amount of regurgitation occurred during the latter phases of ventricular ejection, increasing even as ventricular pressure began to fall. The tracings of patients who had mitral stenosis with no insufficiency were characterized by a sharp, early systolic pressure peak and either a plateaulike sustained pressure elevation during the remainder of ventricular systole or a fall in pressure followed by a rounded wave of low amplitude. The tracings of patients with combined mitral stenosis and insufficiency were characterized by an early systolic pressure peak followed by a secondary rise in pressure beginning in mid-systole which then formed a secondary pressure peak in late systole. This secondary peak was often higher than the primary peak. Though we have shown that the contours of the esophageal and intra-atrial pressure curves are very similar, we do not wish to imply that one can determine the actual level of pressure within the atrium with this technique. Other techniques which have been applied to the study of mitral valve disease, such as cardiac catheterization, 6,7,8 particularly the recording of the pulmonary capillary pressure, 9,10 and electrokymography, 11 supply vital information about cardiopulmonary dynamics. However, none of these yields the type of information about the contour and range of variation of the left atrial pressure pulsation that this technique of esophageal recording does. We feel, therefore, that it offers useful, direct information about the nature of the impairment of the mitral valve.

The Role of a Transverse Arachnoidal Membrane Within the Interpeduncular Cistern in the Passage of Pantopaque into the Cranial Cavity

The passage of Pantopaque into the middle and anterior cranial fossae during myelography has received little attention. The medium enters the skull by way of the medullary, pontine, and interpeduncular cisterns. Occasionally the column is restrained in the interpeduncular cistern as if against a curtain, and spillage does not occur unless the head is flexed or tilted. In an effort to explain this, observations were made of the basilar cisterns at necropsy as the brain was removed from the cranium, and the basilar arachnoid dissected immediately thereafter. After removal of the calvarium, retraction of the frontal lobes brings the optic nerves and chiasm into view (Fig. 1, A). Arachnoidal tags pass to the chiasm. The infundibulum and tuberculum sellae appear when the optic nerves are cut and retracted (Fig. 1, B). The oculomotor nerves can be identified crossing the lateral aspects of the interpeduncular cistern to enter the cavernous sinuses (Fig. 1, C). When the tentorium cerebelli is dissected away the ...

Bronchography in Asthmatic Patients, with the Aid of Adrenalin

Bronchography becomes an important diagnostic procedure in asthmatic patients when the possibility of a coexistent bronchiectasis must be investigated. In our experience this procedure has proved difficult, and adequate visualization often has not been obtained because of inability of the patient to co-operate. An effort was made, therefore, to modify the technic so as to diminish the attendant discomfort. On the assumption that part of the difficulty might be due to edema, spasm, or secretions within the bronchial tree, a preliminary period of dehydration was instituted. This proved to be of no value. Dehydration with the subcutaneous administration of 0.5 to 1.0 c.c. of a 1:1,000 solution of adrenalin immediately before the intratracheal instillation of iodized oil was then tried with much better results. It soon became evident, however, that dehydration was unnecessary, and that the subcutaneous injection of adrenalin was sufficient to enable most patients to co-operate comfortably. Adequate bronchogra...

Electrocardiographic changes during pneumoencephalography

Abstract Electrocardiographic changes indicative of increased vagal activity occur during encephalography.