John G. Piper

Pathogenesis and treatment of growing skull fractures

BACKGROUND Growing skull fractures are poorly understood complications of pediatric skull fractures. METHODS A retrospective review of skull fractures at our institution from 1980-1993 revealed 10 patients with growing skull fractures. The age at injury ranged from 1-144 months, with 9 of 10 patients being under one year of age. The etiology of these fractures included falls, motor vehicle accidents, and child abuse. On average, growth of the fracture was diagnosed 14 months after the initial injury. RESULTS Six patients have had magnetic resonance imaging (MRI) with one demonstrating leptomeningeal cyst herniation, two having brain herniation, and three having both brain parenchyma and leptomeningeal cyst herniation. All patients had malacic cortex underlying the fracture, but there was no evidence of intracranial hypertension. Nine patients have undergone craniotomy with excision of granulation tissue and gliotic brain, dural repair, and cranioplasty using surrounding normal skull. There were no surgical complications or recurrences. CONCLUSIONS Brain/leptomeningeal cyst herniation through a dural rent, without MRI evidence of increased intracranial pressure, implicates physiologic growth and brain cerebrospinal fluid (CSF) pulsations as the cause of fracture enlargement.

Response of intractable pain to continuous intrathecal morphine: a retrospective study

&NA; We have treated 37 patients with intractable pain (35 with cancer‐related pain) by continuous intrathecal morphine infusion via implanted pump. These patients were carefully selected according to specific criteria, and each demonstrated a significant reduction in pain following a test dose of intrathecal morphine. All patients had good pain relief from intrathecal morphine infusion, even with pain located in cervical dermatomes. Systemic narcotics could be withdrawn from most patients. Significant side effects were rare and typically self‐limited. Many patients required gradually increasing doses, seemingly related to disease progression. Two patients with non‐malignant pain have had variable dose requirements over 28 and 44 months without clear tolerance. In these patients we observed a reduction in side effects associated with systemic opioids when continuous intrathecal opioid infusion was instituted. Intrathecal opioid administration may have fewer complications than ablative pain relief procedures. In properly selected patients, this method offers an effective alternative for pain relief.

Characterization of neurons in the area of the medullary lateral reticular nucleus responsive to noxious visceral and cutaneous stimuli

In halothane-anesthetized rats, 283 caudal medullary neurons responsive to colorectal distension (CRD) were characterized using extracellular electrodes. Neurons inhibited by CRD (n = 82) were in the area dorsal to the lateral reticular nucleus (LRN). Most neurons excited by CRD (n = 130) were located within or immediately adjacent to the LRN, were excited by noxious heat and/or noxious pinch of at least half the body surface and were called bilateral nociceptive specific (bNS) neurons. bNS neurons had accelerating responses to graded CRD (threshold: 20 +/- 2 mmHg). Ten of twelve bNS neurons tested could be antidromically activated by electrical stimulation of the midline cerebellum. Other neurons excited by CRD (n = 71) had mixed responses to cutaneous stimuli and were generally located in the area dorsal to the LRN. Increases in blood pressure due to intravenous phenylephrine did not significantly alter the spontaneous activity of neurons excited by CRD, but altered spontaneous activity (12 excited, four inhibited) in all neurons tested which were inhibited by CRD. Decreases in blood pressure produced by intravenous nitroprusside produced a reciprocal response in most neurons inhibited by CRD and had a delayed onset (20-30 s after bolus administration) excitatory effect on 21 of 27 units excited by CRD. Combined with other studies, these data suggest a role for neurons within and adjacent to the LRN in the modulation of visceral nociception. They also implicate a role for the cerebellum in visceral nociceptive processing.

Herniated thoracic disks: treatment and outcome.

The optimal surgical approach for thoracic disk herniation is controversial, and long-term follow-up is poorly documented. We retrospectively reviewed the records of 31 patients who underwent surgery for herniated thoracic disks at our institution during a 17-year period (1975-1992). Two patients had multiple disk herniations; 16 of 33 herniated disks occurred at or below the T10-11 level. There were three surgical approaches to diskectomy: laminectomy in four patients, transpedicular surgery in 12, and costotransversectomy in 15. Weakness resolved postsurgery in nine of 18 patients. One patient transiently deteriorated neurologically after a laminectomy, three had wound infections, and two required second operations for their herniated disks. Postsurgery half the patients with symptoms continued to have pain or weakness.

Perioperative Management and Surgical Outcome of the Acromegalic Patient with Sleep Apnea

ABSTRACT: SLEEP APNEA IS a rare complicating factor of acromegaly associated with a high risk of perioperative airway compromise and unclear response to transsphenoidal resection of the underlying pituitary tumor. We reviewed four acromegalic patients with sleep apnea and documented postoperative objective and subjective improvement of their sleep disorders. The pathogenesis of this disorder and safe perioperative airway management are discussed.

The effect of morphine on responses of mediodorsal thalamic nuclei and nucleus submedius neurons to colorectal distension in the rat.

In halothane-anesthetized rats, we characterized the responses of single neurons in the nuclei of medial thalamus (MT), specifically the mediodorsal thalamic nucleus (MD) and the nucleus submedius (Sm), to a noxious visceral stimulus (colorectal balloon distension, CRD), and studied the effects of intravenous morphine (Mor) on these responses using standard extracellular microelectrode recording techniques. 62 MD and 46 Sm neurons were isolated on the basis of spontaneous activity. 47 of the MD neurons (76%) responded to CRD, of which 70% had excitatory and 30% had inhibitory responses. 38 of the Sm neurons (83%) responded to CRD, of which 89% had excitatory and 11% had inhibitory responses. Responses of MD and Sm neurons excited by CRD were related significantly to distension pressure (20-100 mmHg), with maximum excitation occurring at 60 and 100 mmHg, respectively. MD neurons inhibited by CRD also had graded responses to graded CRD, with maximum inhibition occurring at 80 mmHg. The responses to noxious (pinch, heat) and nonnoxious (tap, brush) cutaneous stimuli were studied in 59 of the MD and 44 of the Sm neurons isolated. 22 of the MD neurons (37%) studied had cutaneous receptive fields, of which 59% were large and bilateral, 41% were small and usually contralateral receptive fields. 55% of these neurons were nociceptive-specific, 45% responded to both noxious and nonnoxious cutaneous stimulation. 29 of the Sm neurons (66%) studied had cutaneous receptive fields, of which 72% were large and usually bilateral, 14% were small and bilateral, 14% were small and contralateral receptive fields. 90% of these neurons were nociceptive-specific, 10% responded to both noxious and nonnoxious stimulation. No MD or Sm neurons responded exclusively to nonnoxious cutaneous stimulation. Mor (0.125, 0.25, 0.5 and 1 mg/kg I.V.) attenuated MD and Sm neuronal excitatory responses to CRD in a dose-dependent fashion, abolishing evoked activity with a dose of 0.5 mg/kg (p < 0.05) and 1 mg/kg (p < 0.05), respectively. Naloxone (0.4 mg/kg I.V.) reversed the effects of Mor. Mor and naloxone had no effects on spontaneous activity. These data support the involvement of MD and Sm neurons in visceral nociception, and are consistent with a role of Sm in affective-motivational, and MD in both sensory-discriminative and affective-motivational aspects of nociception.

The effect of spinal analgesia on visceral nociceptive neurons in caudal medulla of the rat.

UNLABELLED A population of neurons resident in the caudal ventrolateral medulla are excited by noxious cutaneous and visceral stimuli from large portions of the body. These neurons act as monitors of ascending nociceptive information, and we hypothesized that they would be inhibited by spinally administered analgesics in a clinically relevant fashion. Rats were anesthetized with oxygen/ halothane. The caudal medulla was surgically exposed, and a catheter placed into the intrathecal space overlying the lower thoracic spinal cord via the surgical site. Single medullary neurons were characterized for responses to cutaneous and visceral (colorectal distension) stimuli. The effects of i.v. and intrathecally administered morphine and lidocaine were determined. The intrathecal infusion of morphine for 6 days before testing was also used as a pretreatment. Colorectal distension-evoked responses of medullary nociceptive neurons were inhibited in a dose-dependent, naloxonereversible fashion by intrathecal and i.v. morphine (50% effective dose values: 3.5 and 440 microg/kg, respectively). Intrathecal lidocaine abolished responses to colorectal distension and produced a spinal level at doses producing minimal effects when administered systemically. Prior treatment with an infusion of morphine produced tolerance to the effects of subsequent intrathecal morphine administration. These findings support the use of this preparation as a neurophysiologic model of spinal analgesia. IMPLICATIONS Neurons in the brainstem, isolated electrophysiologically, were used as whole body monitors of pain-related activity in the rat. As a neurophysiologic model of nociception, this preparation may prove useful for the study of regionally administered analgesics and local anesthetics.

Sphenoid Wing Meningioma Progression after Placement of a Subcutaneous Progesterone Agonist Contraceptive Implant

A causal relationship between sex steroids and meningioma proliferation has long been suspected. We report a case of the clinical progression of a sphenoid wing meningioma after the placement of Norplant, a subcutaneous contraceptive implant containing levonorgestrel, a progesterone agonist. Although not proof of causation, this observation lends further credence to the importance of progesterone receptors in the growth and possible treatment of meningiomas.

The effect of morphine on responses of nucleus ventroposterolateralis neurons to colorectal distension in the rat.

In 71 halothane-anesthetized rats, we characterized the responses of single neurons in the nucleus ventroposterolateralis (VPL) of the thalamus to a noxious visceral stimulus (colorectal balloon distension; CRD) and studied the effects of intravenous morphine on these responses using standard extracellular microelectrode recording techniques. One hundred nine neurons were isolated on the basis of spontaneous activity. Sixty-four (59%) responded to CRD, of which 52 (81 %) had excitatory and 12 (19%) had inhibitory responses. Neurons showed graded responses to graded CRD pressures (20-100 mmHg), with maximum excitation or inhibition occurring at 80 mmHg. Responses to noxious (pinch, heat) and innocuous (brush, tap) cutaneous stimuli were studied in 95 of the VPL neurons isolated. Eighty-three of these neurons (48 CRD responsive and 35 CRD nonresponsive) (87%) had cutaneous receptive fields, of which 96% were small and contralateral and 4% were large and contralateral or bilateral. Ninety-four percent of these neurons responded to both noxious and innocuous cutaneous stimulation, and 6% responded to only noxious stimulation. No neurons responded solely to innocuous stimulation. Cumulative doses of morphine (0.125, 0.25, 0.5, 1, and 2 mg/kg, i.v) produced statistically significant dose-dependent attenuation of neuronal responses to CRD. Naloxone (0.4 mg/ kg, i.v.) reversed the effects of morphine. Morphine and naloxone had no significant effects on spontaneous activity. These data support the involvement of VPL neurons in visceral nociception and are consistent with a role of VPL in sensory-discriminative aspects of nociception.