Donald L. Myers

Complications of lumbar spinal fusion with transpedicular instrumentation

Transpedicular screw fixation systems are coming into wide use as an adjunct to lumbar spinal fusion procedures. This 5-year series included 486 patients who underwent 533 variable screw placement precedures for diseal, degenerative, and spondylolytic problems. The wound infection rate was 2.6%: 0.6% deep, 0.9% graft, and 1.1% superficial. The neural injury rate was 1.1% overall: 0.6% related to posteriod lumbar interbody fusion and 0.6% related to instrumentation. Technical problems per procedure included 8.1% difficult screw placement, 5.6% nut loosening, and 4.3% screw breakage (1.1% per screw placed). Device modifications have reduced the indicence of screw breakage and nut loosening. No device-related nural injuries occurred in the last 333 procedures. With experience, the device can be applied safely without significantly increasing the risk of neural injury or morbidity.

Surgical Management of the Frontal Sinus

&NA; The management of frontal sinus injury from trauma or operation has been controversial. Case reports and extensive literature review emphasize the importance of careful treatment of the frontal sinus whenever it is violated. The principles of management are reviewed. (Neurosurgery 15:593‐596, 1984)

Total temporal bone resection for squamous cell carcinoma.

Because of unsatisfactory results in treatment of malignant conditions of the temporal bone, a technique for total en bloc resection of the temporal bone and carotid artery was reported by Graham et al. in 1984. The procedure involves resection of the internal carotid artery, cranial nerves VI through XII, and structures adjacent to the temporal bone. Experience with two additional cases led to numerous modifications in the recommended procedure, as reported by Sataloff and Myers. Additional clinical experience with this technique and its complications has resulted in further modification. Additional pitfalls and specific changes in technique from previous reports are discussed in detail, including a new procedure to assure the adequacy of contralateral venous outflow.

Vestibular Nerve Section

INTRODUCTION Vestibular nerve section is considered to be the most effective surgical procedure for control of intractable symptoms secondary to labyrinthine and eighth nerve function. This study was developed to retrospectively evaluate the efficacy of vestibular nerve section in patients treated for disabling labyrinthine dysfunction. METHODS A retrospective review of hospital and office records was carried out on 39 patients who underwent vestibular nerve section. All patients received a comprehensive questionnaire to subjectively evaluate efficacy. RESULTS Questionnaires were returned from 36 of 39 patients. Follow-up averaged 51 months. A decrease in vertiginous attacks was reported by 94% of patients. An improvement in activity tolerance was reported by 30% of patients. Preoperative tinnitus and ear fullness reportedly improved after surgery in 53% and 65% or patients respectively. Complications encountered included cerebrospinal fluid (CSF) leak (six patients), meningitis (two patients), and intracranial fluid collection (one patient). CONCLUSION Vestibular nerve section is a relatively safe and effective method of treatment for intractable vertigo.

Arachnoiditis presenting as a cervical cord neoplasm: two case reports.

Neurological evaluation supplemented by myelography has been highly successful in diagnosing spinal cord tumors. Our experience shows that a widening of the cord on myelography is not always diagnostic of spinal cord tumors. Two patients who presented clinically with evidence of spinal cord tumor and had a widening of the cord on myelography were found to have severe cervical arachnoiditis without any evidence of intrinsic cord abnormality. Hence, cervical arachnoiditis should be considered in the differential diagnosis of spinal cord tumor on myelography.

Middle Turbinectomy Complicated by Cerebrospinal Fluid Leak Secondary to Ethmoid Encephalocele: Transethmoid Repair

The value of middle turbinectomy for cephalalgia in carefully selected patients has been established. Although surgical treatment for middle turbinate syndrome is usually easy and safe, it may result in complications especially in the presence of unrecognized malformations of the anterior skull base. In the patient presented, cerebrospinal fluid rhinorrhea that was due to an ethmoid encephalocele occurred 1 month following surgery. An intranasal, transethmoid subfrontal craniotomy was devised to repair this defect under direct vision without subjecting the patient to the added risks of subfrontal craniotomy through external incisions. The case is reported to highlight an uncommon surgical hazard and a new approach to its repair and to address questions regarding the adequacy of the standard preoperative evaluation.

Total Temporal Bone Resection

Traditional therapeutic approaches for malignancies of the temporal bone have produced unacceptably low survival figures. The morbidity and mortality associated with temporal bone cancer justify extensive surgery. Total temporal bone resection can be performed successfully in the hands of an experienced skull-base surgical team. By circumscribing the tumor rather than transgressing it, this procedure follows generally accepted principles of oncologic surgery. This procedure also shows promise in resection of extensive, carefully selected, recurrent benign tumors. We believe this approach offers hope for improved survival in patients with malignancy of the temporal bone. Further refinements in technique are suggested by each new case. Additional experience and long-term follow-up are needed to assess the efficacy of this procedure. The interest, expertise, and active participation of the operating room nursing team are critical to the success of this surgery. Ideally, not only intraoperative participation but also preoperative assessment and postoperative support should be routine. Close cooperation and extensive communication among the surgeons and nurses are essential.

Cervical Spine Injury Associated with Minor Head Trauma

The patient who has sustained minor head trauma has almost certainly also experienced unusual force delivered to the cervical spine. With the possible exception of direct crushing trauma, head injury is associated with rotation, flexion, extension, compression, or other force vectors applied to the neck. While the most extreme failures of the cervical spine may manifest as fractures, dislocations, and acutely ruptured discs, other injuries can be more subtle, resulting in “chronic” conditions, such as neckache, headache, musculoligamentous sprain, cervical radiculopathy, thoracic outlet syndrome, and other problems. A brief review of some of these problems highlights the importance of their consideration in the evaluation and management of patients with head trauma.

Complications of Lumbar Spinal Surgery with Transpedicular Fixation

Spinal fusion has been an important management technique for various de-generative and traumatic conditions of the lumbar spine. The addition of internal fixation during arthrodesis allows correction of deformity that might not otherwise be feasible. Instrumentation also will minimize motion during graft incorporation and there is substantial evidence this probably increases the rate of solid arthrodesis, especially over multiple anatomic motion segments [1–3].