Henry H. Schmidek

The Cerebral Venous System

&NA; The authors discuss the gross and microscopic anatomy and the physiology of the cerebral venous system. Cerebral veins under pathological circumstances (hypercapnia, arterial hypertension, and increased intracranial pressure), pharmacological observations, the venous blood‐brain barrier, and traumatic involvement are reviewed. Neoplastic involvement and radiological aspects are included. Surgical reconstruction of venous sinuses (including the Donaghy technique), tumor removal, sinus thrombectomy, and extraanatomical bypass of the transverse sinus are discussed. (Neurosurgery 17:663‐678, 1985)

Delayed Traumatic Intracerebral Hematoma: Report of 15 Cases Operatively Treated

Fifteen cases of delayed traumatic intracerebral hematoma (DTICH) operatively treated are reported. Patients who are awake or only drowsy on admission (Coma Grades 1 and 2, Grady scale) often undergo dramatic sudden neurological deterioration 48 to 72 hours after admission. Emergency computed tomographic scanning and prompt craniotomy for hematoma evacuation yield excellent clinical results in the majority of cases. Patients presenting in deeper grades of coma (Grades 3 to 5, Grady scale) who develop DTICH do quite poorly, often because the diagnosis is difficult to make and consequently is delayed. The development of DTICH is in our experience highly unpredictable, and often no clear secondary cause (hypercapnia, hypoxia, bleeding diathesis) can be demonstrated.

Spinal subdural hematoma: case report and review of the literature.

A case of lumbar spinal subdural hematoma in a patient who had been on anticoagulant therapy is reported. Thus far 19 cases of spinal subdural hematoma have been reported in the literature, the majority in patients with a bleeding diathesis and after a lumbar puncture. Our case is the third reported to be in association with anticoagulant therapy. The hematoma was lumbosacral, in contrast to the usual location in the dorsal-lumbar area. A possible mechanism for the production of spinal subdural hematoma after a lumbar puncture is discussed. An early decompressive laminectomy and evacuation of the hematoma is the recommended treatment to obtain the best possible recovery of neurological function. (Neurosurgery, 5: 614--616, 1979).

Compressive Myelopathy Associated with Type VI Mucopolysaccharidosis (Maroteaux-Lamy Syndrome)

Spinal cord compression with resultant myelopathy is a frequent occurrence in patients with mucopolysaccharidoses. Etiological factors include developmental abnormalities of the cervical spine and infiltration of the dura mater by the accumulated products of mucopolyssacharide metabolism. Compression at the thoracolumbar junction is rare, but was found in a child with the characteristic physical and biochemical stigmata of the Maroteaux-Lamy syndrome (mucopolysaccharidosis VI). An anterolateral approach to remove the compressing bony elements resulted in symptomatic improvement. Careful radiological evaluation is required so that all surgical options can be considered. Patients with metabolic storage diseases and the capacity for normal intellectual function warrant aggressive surgical care to optimize neurological function.

Transoral unilateral facetectomy in the management of unilateral anterior rotatory atlantoaxial fracture/dislocation: a case report.

An unusual case of unilateral anterior rotatory atlantoaxial fracture/dislocation with neurological deficit is presented. The injury could not be reduced by skeletal traction, but was successfully reduced by partial facetectomy at C-1, C-2 accomplished through a transoral exposure of the atlantoaxial region combined with labiomandibularglossotomy. To the best of our knowledge, this is the first instance of an injury of this type to be so managed. The details of the operative procedure are described, and the subject of rotatory atlantoaxial dislocation is reviewed.

Management of acute unstable thoracolumbar (T-11-L-1) fractures with and without neurological deficit.

A one-stage anterilateral decompression of the thoracolumbar spine with Harrington rod alignment and posterior fusion has proven to be an excellent approach to the management of unstable fractures between T-11 and L-1. Twenty-six cases are reported in which this tactic was used to decompress neural structures and stabilize the spine. Preoperative computed tomographic scanning and somatosensory evoked responses (SSERs) are useful adjuncts in the patients assessment. Intraoperative SSER studies have allowed monitoring to prevent an increase in the patients neural deficit during operation. Intraoperative myelography is used to provide objective confirmation of the adequacy of the decompression of the spinal subarachnoid space. Satisfactory stability was achieved in all 26 cases reported in this series. Eight of 11 patients with partial neurological deficits returned to essentially normal function within 6 months. None of the patients who were neurologically intact (6 cases) or who had incomplete lesions (11 cases) was made worse by the operation. None of the 9 paraplegic patients regained spinal cord function, although a dramatic improvement in the function of the L-2 and L-3 roots occurred in 1 case. This approach to the management of unstable thoracolumbar fractures is useful, carries with it a low complication rate, and should be a standard part of the neurosurgical and orthopedic armamentarium.

Epidural Morphine for Control of Pain after Spinal Surgery: A Preliminary Report

Epidural opiates have been used successfully for the control of postoperative pain after obstetrical, abdominal, and orthopedic procedures. The use of these agents for the control of pain after operation on the thoracic and lumbar spine is reported. A catheter is inserted under direct vision into the epidural space after semihemilaminectomy and disc excision, posterior decompressive lumbar laminectomy, and anterolateral thoracolumbar decompression and just before wound closure. Excellent postoperative pain relief is achieved for 8 to 20 hours after single epidural injections of between 2 and 6 mg of morphine. Catheters are left in situ for 2 to 5 days. To date, no complications requiring treatment have been encountered with this approach.

Spinal Subdural HematomaCase Report and Review of the Literature

A case of lumbar spinal subdural hematoma in a patient who had been on anticoagulant therapy is reported. Thus far 19 cases of spinal subdural hematoma have been reported in the literature, the majority in patients with a bleeding diathesis and after a lumbar puncture. Our case is the third reported to be in association with anticoagulant therapy. The hematoma was lumbosacral, in contrast to the usual location in the dorsal-lumbar area. A possible mechanism for the production of spinal subdural hematoma after a lumbar puncture is discussed. An early decompressive laminectomy and evacuation of the hematoma is the recommended treatment to obtain the best possible recovery of neurological function. (Neurosurgery, 5: 614--616, 1979).

Fractures of the Sella Turcica

Five recent cases of sella turcica fracture examined at the Medical Center Hospital of Vermont are reported. These fractures are most commonly associated with frontal or maxillofacial trauma and are complicated by cranial nerve palsies, chiasmatic injury, and cerebrospinal fluid rhinorrhea and otorrhea. The mortality rate with these fractures is high because of the associated brain injury. The importance of a detailed endocrine evaluation to detect developing pituitary abnormalities is also emphasized. The accuracy of radiographic diagnosis of these fractures utilizing plain skull films, tomography, and computed axial tomography is reviewed. the importance of cerebral angiography to evaluate the intracavernous internal carotid arteries and the basilar artery is also emphasized, as is the theoretical basis of the pathological findings associated with these fractures.

Hemorrhage-induced alterations of rabbit basilar artery reactivity and sensitivity to serotonin.

Subarachnoid hemorrhage has a profound effect on cerebrovascular reactivity. The present study noted a progressive change in the sensitivity and reactivity of rabbit basilar artery to serotonin after experimentally induced hemorrhage. The basilar artery exhibited an initial diminished response to serotonin for periods up to 6 hours after hemorrhage, whereafter the vessel gradually became hyperresponsive. The hypersensitivity became maximal 36 hours after hemorrhage and then began to return to normal. Such early onset of serotonin hypersensitivity and reactivity after subarachnoid hemorrhage has not been previously reported. The level of tension developed, however, suggests that serotonin alone is unlikely to cause vasospasm. The strict differentiation of spasm into early and delayed components is questioned.