Courtland H. Davis

The Advantages of Early Spine Fusion in the Treatment of Fracture-Dislocation of the Cervical Spine

This Paper is concerned with the advantages of internal fixation and spine fusion early in the treatment of fracture-dislocations of the cervical spine. It is based on a statistical analysis of eighty-four cases of this entity treated within the clinical experience of the authors. It is important to understand the mechanism of injury in each case in order to treat it intelligently. In the treatment of cervical-spine injuries, first consideration must be given to protection of the neural elements. Relieving all pressure from the spinal cord and nerve roots, and putting them at rest, affords the best opportunity for return of function of the neural elenments. To do this with certainty requires accurate reduction of bone elements, followed by internal fixation for immediate stability and spine fusion to prevent late recurrence. The general routine of skeletal traction, internal fixation, and spine fusion constitutes a method of treatment that needs to be varied but slightly in order to include a large percentage of all serious injuries of the cervical spine. The results in thirty-eight spine fusions and forty-six injuries treated conservatively indicate that the patients in whom fusion was done had less residual deformity and a lower rate of recurrence. In addition less time was spent in the hospital or in uncomfortable casts, and less time was spent away from work. The mechanism of injury in cervical-spine fractures and dislocations is discussed in some detail, with emphasis on the hyperextension types. A new interpretation of the roentgenographic findings in a large group of fracture-dislocations with mild anterior displacement shows that approximately half of them were caused by hyperextension rather than flexion as previously thought. Prior to the recognition of this mechanism, it was difficult to understand the severe neurological changes that were frequently present. Placing these cases in the group of hyperextension injuries makes the neurological damage understandable.

False aneurysm complicating carotid endarterectomy.

We present two cases of false aneurysm after carotid endarterectomy with primary arteriotomy closure. In both cases, infection appeared to be the precipitating cause. Both lesions were repaired with a saphenous vein patch graft, but infection in one patient persisted, and recurrence of a false aneurysm required ligation of the common carotid artery. There were no neurological sequelae in either patient. A review of the English language literature, our experience, and personal communications yielded 57 cases of false aneurysm. The overall incidence of false aneurysm after carotid endarterectomy was 0.30%. There was no significant difference in the incidence after endarterectomy alone and that after endarterectomy and patch grafting. A significant increase in neurological deficit occurred only when carotid ligation was used, with a morbidity/mortality of 50% in eight reported cases. Infection was the major cause of false aneurysm after endarterectomy; it occurred in 50% of cases closed primarily without patch grafting. Repair with a saphenous vein patch graft and monofilament synthetic suture, plus liberal use of antibiotics, should be considered in the treatment of this condition.

Giant cell tumors of synovium (pigmented villonodular synovitis) involving the vertebral column

Giant cell tumors of synovium (pigmented villonodular synovitis) involving the vertebral column recently have been seen in two women: the third and fourth cases to be reported in the English‐language literature. Unlike the previously reported cases, both these tumors grew outside the dura and produced symptoms of spinal cord compression. The first case involved lumbar vertebrae 5 and 6; the second, lumbar vertebrae 2 and 3. Even though initial resection of both tumors was incomplete, the patients improved postoperatively. One tumor was known to be unresectable at the time of surgery. In the other patient, a recurrence of symptoms required second and third resections 4 and 8 months after the first, respectively. Although synovial giant cell tumors rarely metastasize, the rate of local recurrence is high, especially if excision is incomplete. For this reason, close follow‐up of patients with lesions in the spinal column is indicated. Increased physician awareness that synovial giant cell tumors can occur in the spine will help to ensure that these tumors are not misdiagnosed in this location.

Hemodynamic status following regional and general anesthesia for carotid endarterectomy.

Summary We prospectively studied 23 patients undergoing carotid endarterectomy under regional (n = 13) or general (n = 10) anesthesia to determine the hemodynamic basis of increased frequency in the need for postoperative vasopressor support when regional anesthesia was used. Anesthesia and postoperative care were conducted without reference to hemodynamic data from pulmonary artery catheterization. Although mean arterial pressure was similar in the two groups postoperatively, 11 of the 13 patients undergoing regional anesthesia and 3 of the 10 patients undergoing general anesthesia required phenylephrine postoperatively. No patient required therapy postoperatively to reduce a systolic pressure exceeding 160 mm Hg. Mean arterial pressure remained below the preoperative baseline value in both groups (p < 0.05 with general anesthesia; p = 0.06 with regional anesthesia) during follow-up. In the general anesthesia group, systemic vascular resistance declined significantly below baseline (p < 0.05) following the operation, accompanied by a decline in mean arterial pressure (p < 0.05) and a higher cardiac output. Intraoperative fluid requirements were greater during general anesthesia than during regional anesthesia (p < 0.01). Pulmonary artery occlusion pressure was lower postoperatively than at baseline in both groups (p < 0.05). Pulmonary artery occlusion pressure was higher in the general anesthesia group despite the greater use of phenylephrine in the regional anesthesia group.

Familial brain tumors: studies of two families and review of recent literature

We studied two families in each of which three or more individuals were affected by brain tumors. In the first family, which had no evidence of neurofibromatosis or tuberous sclerosis, a man, his sister, and her son developed histologically proven gliomas; the mans great uncle was historically reported to have died from a brain tumor, but the exact nature of the tumor was not known. In this family two of the tumors were low grade astrocytomas of the cerebrum, whereas the third was a mixed glioma of the cerebellum. Karyotypic analysis of this tumor showed no marker chromosomes. A second family had a history of an unusual concentration of brain tumors. In one patient the tumor was a histologically verified glioma. Four other patients had historically reported brain tumors, the descriptions of which suggested gliomas. Both families showed involvement of individuals in adjacent generations, although in both instances there were skipped generations. Twins, siblings, or parents and children are the kindred groups affected in most other reported families with multiple brain tumors. The mode of inheritance of brain tumors in these two families and recent literature on the conditions associated with familial brain tumors are discussed.

Myocardial infarction following regional anaesthesia for carotid endarterectomy

From 1969 through 1982, 185 carotid endarterectomies were performed under regional anaesthesia on 153 patients. Of these patients, 38 (25 per cent) had suffered a previous myocardial infarction, 63 (41 per cent) had documented coronary artery disease, and 115 (75 per cent) had hypertension. Anaesthesia was provided by a superficial cervical plexus block. Monitoring consisted of measurement of direct arterial pressure and continuous display of the electrocardiogram. Oxygen was administered by nasal cannula throughout the procedure. Mean arterial pressure was elevated when necessary by infusion of phenylephrine. No patient in this study suffered an acute myocardial infarction. The only cardiac complications consisted of eight episodes of non-life-threatening dysrhythmias, We conclude that regional anaesthesia for carotid endarterectomy is associated with a low risk of perioperative myocardial infarction.RésuméDe 1969 à 1982,185 endartêrectomies de la carotide ont été faites sous anesthésie regionale chez 153 patients. De ces patients, 38 (25 pour cent) avaient déjà eu un infarctus du myocarde, 63 (41 pour cent) avaient une maladie coronarienne documentée et 115 (75 pour cent) souffraient d’hypertension. On pratiquait chez ces patients un bloc du plexus cervical superficiel. On mesurait de façon directe la pression artérielle et on avait un enregistrement continu de l’élecirocardiogramme, On administrait de l’oxygène par canule nasale pendant toute la procédure. La pression artérielle moyenne était augmentée, si cela était nécessaire, par l’infusion de phényléphrine. Aucun patient pendant cette étude n’a subi un infarctus du myocarde. Les seules complications cardiaques ont été 8 épisodes de dysrythmies non menaçantes. Nous concluons que l’anesthésie régionale pour l’endartérectomie de la carotide est associée à un faible risque d’infarctus péri-operatoire.

Intraventricular hemorrhage from pituitary apoplexy

The case of a patient with a massive intraventricular hemorrhage arising from a pituitary chromophobe adenoma is described. This rare and disastrous complication was ascribed to the large suprasellar extension of the tumor and its close proximity to the floor of the third ventricle. Hemorrhage in the tumor extended along the path of least resistance and ruptured into the third ventricle. A partially treated hyperviscosity syndrome and chemotherapy for an unrelated malignancy (multiple myeloma) may have predisposed the patient to the necrosis and hemorrhage in the pituitary tumor.

Fixation of fractures of the lower cervical spine using methylmethacrylate and wire: technique and results in 99 patients.

Surgical stabilization of traumatic fracture-dislocations of the lower cervical spine with wire and methylmethacrylate remains a controversial procedure. Yet, the resultant immediate fixation with minimal patient morbidity seems to indicate that this method provides an ideal stabilization construct. We describe and report the outcome of a technique of posterior cervical fixation with methylmethacrylate and wire for stabilization of traumatic fractures of the lower cervical spine. Over a 12-year period, 124 fracture-dislocations of the lower cervical spine in 99 patients (mean age, 32 years; range, 15-76 years) were treated at this institution using a posterior methylmethacrylate and wire technique. Eighty-two patients had a posterior element fracture; 28 had a vertebral compression with posterior ligamentous injury; and 14 had a ligamentous injury alone. Thirty-six patients were neurologically intact upon admission, while the rest had radiculopathy or partial or complete myelopathy. Ninety-one patients were available for follow-up [mean, 18.6 months; range, 1-100 months (8.33 years)]. Eighty-eight patients (97%) had a stable fixation and 77 (85%) had resumed preoperative activity or were working but with a residual deficit. Complications included fixation failure requiring a second operation in 3 patients, nonlethal pulmonary embolism in 2 patients, lethal pulmonary embolism in 1 patient, and a superficial wound infection in 3 patients (none affected the underlying fixation construct). These results indicate that this technique is a safe, simple, and effective method for stabilizing the lower cervical spine that allows rapid patient mobility with minimal morbidity.

ACTH-producing pituitary adenoma in an infant with cysts of the kidneys and lungs

The light microscopical, electron microscopical and immunohistological features of a rare ACTH‐producing chromophobe adenoma of the pituitary gland in an 11‐month‐old infant are presented. An unusual histological feature was the presence of numerous follicles. These follicles may develop secondary to necrosis of individual tumour cells. There is only one previous report in the literature of a pituitary adenoma occurring in infancy and that tumour also produced ACTH and showed a follicular histological pattern. It is of interest that our patient also had a combination of medullary cysts of the kidneys and congenital peripheral cysts of the lungs. The association of cysts in lungs with cysts in kidneys also has been reported only once previously. We conclude that the occurrence of cysts in kidneys and lungs and a pituitary tumour in infancy represents a bizarre coincidence although an unknown common embryonic insult to these organs cannot be ruled out.

The effects of regional and general anesthesia on blood pressure control after carotid endarterectomy.

Summary We retrospectively reviewed the influence of preoperative blood pressure control and regional vs. general anesthetic techniques on the incidence of intraoperative and postoperative (recovery room and intensive care unit) hypotension and hypertension in 249 carotid endarterectomy patients. Preoperative blood pressure was classified as uncontrolled hypertension (systolic blood pressure ≥ 170 mm Hg and/or diastolic blood pressure ≥ 95 mm Hg), controlled hypertension (blood pressure <170/95 mm Hg on chronic antihypertensive therapy), or normotension (blood pressure <170/95 mm Hg without antihypertensive therapy). Hypotension, as defined by the requirement for vasopressor administration to maintain a systolic blood pressure of at least 120 mm Hg, occurred more frequently after regional than after general anesthesia (p < 0.05). Postoperative hypertension was defined as a systolic blood pressure ≥ 200 mm Hg and/or a diastolic blood pressure ≥ 110 mm Hg in the recovery room or in the Intensive Care Unit. Preoperative hypertension was not associated with acute postoperative hypertension in the intensive care unit in either the regional anesthesia (n = 190) or the general anesthesia (n = 59) groups, although with either type of anesthesia, preoperative hypertension was associated with an increased incidence of hypertension in the recovery room (p < 0.01 regional; p < 0.005 general).