Harold A. Wilkinson

Percutaneous radiofrequency upper thoracic sympathectomy: a new technique.

The author describes a new technique for performing unilateral or bilateral upper thoracic sympathectomy safely, effectively, and more easily than by any of the surgical methods now in use. The technique described is one of percutaneous radiofrequency sympathectomy, which is usually done on a day surgery or outpatient surgery basis. The technique has been effective and well tolerated in a small group of patients.

Intracranial hypertension and cerebrospinal fluid production in dogs: Effects of furosemide

A method using chronically prepared, anesthetized dogs was devised for studying the effects of treatments of intracranial hypertension induced by applying a reversible extradural mass lesion while simultaneously measuring production of cerebrospinal fluid. This was measured with a ventricular-cisternal perfusion technique in which the rate of cisternal outflow could be controlled by a pump and matched to the inflow, allowing intracranial pressure to fluctuate despite simultaneous measurement of cerebrospinal fluid formation. Elevations of intracranial pressure to the range 20 to 35 Torr were induced and maintained during perfusion, but elevations above 35 Torr would not permit continued perfusion. At normal intracranial pressure, 10 Torr or less, rates of cerebrospinal fluid formation were the same whether the outflow controlling pump or free outflow was used. Formation of cerebrospinal fluid decreased progressively as intracranial pressure increased above 20 Torr. It also decreased with time after the start of perfusion during the course of 5 h, but returned to the initial range during the control phase of subsequent experiments in the same animal. Furosemide, 3 mg kg-1, i.v., had no significant effect on rate of formation but did induce a small decrease in ICP in time-controlled experiments in which i.v. fluid replacement limited net fluid losses to 20 ml kg-1 with no change in mean arterial or central venous pressures.

The Role of Improper Surgery in the Etiology of the Failed Back Syndrome

In the United States, approximately two thirds of all patients enrolled in chronic pain centers suffer from the failed back syndrome. Neurosurgeons perform 100,000 operations for lumbar disc disease every year, and orthopedic surgeons perhaps perform a similar number.6 It is estimated that between 20% and 40% of these operations are unsuccessful and result in the failed back syndrome. Dr. William Sweet, former Professor and Chairman of Neurosurgery at the Massachusetts General Hospital, has estimated that, in contrast, only approximately 10% of patients enrolled in European pain clinics suffer from the failed back syndrome.7 The reasons for this discrepancy are likely to be multiple, including, perhaps, Europeans’ greater stoicism and a less supportive acceptance of disability and non-productivity.

Introduction: Etiology, Diagnosis, and Therapy

Management of a patient with a failed back following unsuccessful back surgery poses a serious problem to all health practitioners who attempt to aid these unfortunate sufferers. Neurosurgeons, orthopedists, psychiatrists, family practitioners, physical therapists, nurses, and even marriage counselors all too often find themselves frustrated in their therapeutic efforts. Many of these patients fail to respond to prolonged therapy, but the situation is certainly not hopeless. The list of therapeutic possibilities is, in fact, quite long and varied. Unfortunately, in many instances the failure to achieve success must be attributed to a lack of flexibility and versatility in the therapeutic efforts expended on these patients. One’s approach to these problems must be based on a systematic awareness of the potential therapies available and careful tailoring of therapeutic efforts to the patient’s specific symptoms, physical findings, and psychologic makeup.

Growth of 9-L and RT 9 gliosarcoma in female rats

Published studies of 9-L and RT9 gliosarcoma have been done only in male rats and it is widely assumed that these tumors do not grow in female rats. In this study 9-L and RT 9 gliosarcoma was inoculated into the brains of male and female Fisher CD rats. The tumors grew with essentially the same incidence and survival time in both sexes, confirming that female rats can be used as well as male rats in experiments using RT9 and 9-L gliosarcomas.

Precise Diagnosis of Specific Syndromes

Patients with the failed back syndrome should usually be treated initially with nonspecific and generally safer therapies. When simpler therapies fail, continued successful therapy must be based on a precise understanding of the disorder to permit an appropriate choice of specific therapy. As our knowledge of the complexity of the disorders that may cause the failed back syndrome increases, it becomes more apparent that the “wastebasket diagnoses” of postoperative back, chronic lumbar derangement, or even the all-encompassing term failed back syndrome are not sufficiently precise to permit accurate therapy for many patients. Attempts at diagnosing precise causes of the failed back syndrome should be undertaken in a systematic fashion. A carefully taken history is vitally important in all aspects of medicine, and this dictum holds true in understanding the causes of the failed back syndrome.

Team Approach or Individual Effort

Much of what is currently written about treatment of pain patients, including failed back syndrome patients, assumes, recommends, or even proposes to mandate a team approach. In practice, how valuable is this approach? Are those who insist that it is the only valid approach correct in this assumption, or are they merely overly zealous?