Joseph A. Epstein

NERVE ROOT COMPRESSION ASSOCIATED WITH NARROWING OF THE LUMBAR SPINAL CANAL

During a study of low back pain and radiculitis, certain patients were observed who did not conform to the criteria of the classical compression syndromes caused by osteophytes or herniated discs (Epstein, 1960). Symptoms and signs of nerve root compression were far more severe than could be explained by the presence of relatively minor intrusions. Pre-operative myelograms disclosed single and often multiple defects of varying extent, some with complete block suggesting the presence of lesions more extensive than were encountered at operation. A significant common finding in these patients was the difficult operative exposure of the interspace caused by unusually prominent, bulbous articular facets and thickened, vertically orientated laminae. The spinal canal itself was shallow and exploration within its narrow confines was remarkably restricted. It became apparent that liberal unroofing of the spinal canal over the course of the nerve roots was as important for relief of symptoms as the excision of disc protrusions and spurs. In reaching these conclusions, we were aided by previous experience in the management of a 15-year-old achondroplastic dwarf with compression of the conus and cauda equina by multiple lumbar intervertebral discs bulging into a congenitally narrowed spinal canal (Epstein and Malis, 1955). The deformities of the neural arches and the concomitant reduction in the width and depth of the spinal canal were similar in this patient and those of the present series. The protruding discs in the floor of the canal were left undisturbed, adequate relief being obtained by laminectomy alone. Gratifying restoration of function with relief of pain followed a decompressive laminectomy of the twelfth dorsal and of all the lumbar vertebrae, and there has been no recurrence of symptoms since January, 1954. Even a small herniated intervertebral disc in an achondroplastic dwarf may cause catastrephic trauma to the spinal cord and cauda equina because of the absence of available space for displacement of these structures within the narrow bony canal (Spillane, 1952; Schreiber and Rosenthal, 1952; Vogl and Osborne, 1949). A similar lack of space predisposes the patients in the present group to the untoward effects of neural compression by minimal intrusions.

The surgical management of cervical spinal stenosis, spondylosis, and myeloradiculopathy by means of the posterior approach.

No firm statistical evidence exists establishing the superiority of the anterior or the posterior approach in the management of spondylostenosis, although some sense of order is evolving. In general the consensus suggests that in spondylostenosis, the anterior approach may be preferred for disc or segmental osteophyte intrusions limited to one or two levels. Laminectomy is the preferred procedure in patients with a narrowed canal and multiple level involvement. The surgeons personal preference and experience remains the dominant factor. Patients with congenital stenosis involving all of the major segments, with or without superimposed developmental changes, require more extensive laminar decompression with proper attention to the craniocervical junction where anomalies may occur. The success of laminectomy is dictated by the preservation of cervical lordosis. In patients with major dorsally located abnormalities such as hyperlordosis, shingling, and arthrosis with hypertrophy of the yellow ligaments, posterior decompression is essential. Subsequent stabilization is rarely required with proper surgical and postoperative care. Both an anterior and posterior approach may be indicated in unique circumstances of spondylostenosis complicated by subluxation and instability.

Lumbar intervertebral disk herniation in teenage children: recognition and management of associated anomalies.

Herniated disks in children and adolescents can be extremely disabling and difficult to diagnose because of the paucity of neurologic abnormalities and the consequent suspicions of hysteria. The Laségue sign is often the only consistent positive finding, and when persisting without remission, justifies early diagnostic studies such as CT scanning, and electromyography. Myelography may be avoided if these studies are definitively diagnostic. The almost uniformly good results that follow diskectomy do not justify prolonged conservative care. Management is facilitated by awareness of often unrecognized structural abnormalities found in these patients. These include spinal stenosis, lateral recess narrowing, and transitional vertebra. Spinal fusion, while rarely indicated, should be considered where motion segment instability contributes to persistent backache. The management of 25 patients is recorded. Twenty-one of these presented with an anomaly worthy of record requiring modifications in surgical technique to provide proper decompression and lasting relief of symptoms

Far lateral lumbar disc herniations and associated structural abnormalities : an evaluation in 60 patients of the comparative value of CT, MRI, and myelo-CT in diagnosis and management

The management of 60 patients with far lateral lumbar disc herniations operated on over a 5-year period are presented. These lesions were located superiorly within the neural foramens beneath or distal to the facet joints. The type of surgery performed in 43 of 60 (72%) of these patients was significantly altered by the presence of diffuse and lateral recess stenosis. This was better appreciated on the myelogram and myelo-CT (M-CT) studies than with the noncontrast CT and MRI examinations alone. Myelo-CT findings were particularly valuable in assessing patients who had previous surgical procedures.

Limbus lumbar vertebral fractures in 27 adolescents and adults.

Fractures of the lumbar vertebral limbus involve varying degrees of fragmentation of the peripheral ring apophysis, located at the posterior superior or posterior inferior margins of the mid to lower lumbar vertebrae. Four types, uniquely found in adolescents and young adults, have been described. Type I lesions consist of avulsions of the posterior cortical vertebral rim. Type II fractures are composed of central cortical and cancellous bone fractures. Type III lesions are more lateralized chip fractures. Type IV fractures span the entire length and breadth of the posterior vertebral margin between the end plates. The clinical, neuroradiologic, and surgical management of 27 patients with these four types of lumbar limbus vertebral fractures are reviewed. The data regarding location and type of fracture were critical for planning piecemeal surgical resection with a downbiting curette, tamp, and mallet technique.

Degenerative spondylolisthesis with an intact neural arch: a review of 60 cases with an analysis of clinical findings and the development of surgical management.

The treatment over the past 12 years of 60 patients with degenerative spondylolisthesis with an intact neural arch is reviewed. The patients averaged 65 years of age, with women outnumbering men by a ratio of 2:1. Symptoms in the lower extremities had been present for 3 months to 10 years, although varying back pain had existed for longer periods. Two-thirds showed signs of motor dysfunction. Sensory alterations and a positive Las ègues sign could be demonstrated in only one-half of the patients studied. Four of 5 patients developed intermittent neurogenic claudication, with varying evidence of painful radiculopathy. The marked disability caused by claudication contrasted sharply with the lesser neurological changes, and these patients required early surgical decompression. Diagnostic studies included electromyography, plain x-ray films, tomography, computed tomographic scanning, and myelography. The latter outlined a relative stenosis caused by olisthesis as well as arthrotic and spondylotic changes that determined the extent of decompressive operation required. The L-4, L-5 interspace was involved in 56 patients, L-3, L-4 was involved in 2, and L-5, S-1 was involved in 2. The ideal operation with L-4, L-5 olisthesis included complete laminectomy of L-4 and L-5 with unroofing of the lateral recesses and foraminotomy. This more extensive procedure was justified because of the failures encountered in previous patients in whom inadequate decompression had been performed. Among failures, obesity, diabetes, hyperlordosis, and extensive long-standing dysfunction were prominent. The relief of symptoms of intermittent neurogenic claudication was the most gratifying response observed. There was no unusual morbidity.

Lap-sash three point seat belt fractures of the cervical spine

Cervical spine injuries associated with three-point fixation lap-sash seat belts result from Impact against the sash. While such injuries are infrequent and often without serious neurologic sequelae, they may produce serious deficits with grave injuries. Flexion-extension fractures of the lower cervical vertebrae, fractures of the transverse and spinous processes of the lower cervical and uppermost thoracic vertebrae, discal disruptions, and brachial plexus avulsions may occur. Of the 3 patients reported here, 2 escaped serious damage.

Subepicranial hydroma. A complication of head injuries in infants and children.

Summary The accumulation of spinal fluid beneath the epicranius as a soft, fluctuant mass is a complication of head injury with fracture in children. The swelling is nontender and is usually not associated with any significant evidence of brain injury. It appears within hours or days after the trauma, which usually is of the blunt type. Once apparent, the swelling may increase dramatically in size and, at times, envelop the entire hemicranium. A marginal rim is present in some of the more restricted collections, usually in the parietal region. Roentgenograms disclosed linear fractures in 80 per cent of the cases, which are most often in the parietal area and often cross a suture line. The duraarachnoidal tear occurs at the fracture line and permits the escape of cerebrospinal fluid into the subepicranial areolar tissue. The fluid is absorbed spontaneously; aspiration is contraindicated because of the possibility of introducing infection. No treatment is required.

Traumatic myelopathy in a seventeen-year-old child with cervical spinal stenosis (without fracture or dislocation) and a C2-C3 Klippel-Feil fusion. A case report.

A 17-year-old white male patient sustained a cervical hyperextension injury while body surfing. Plain cervical radiographs, tomography, and CAT scan showed neither fracture nor subluxation, but congenital narrowing of the spinal canal and fusion of C2-C3 (Klippel-Feil). Clinically, he had a central cord syndrome, characterized by a motor dominant myelopathy. The conservative management of this patient with a central cord injury in the presence of spinal stenosis and a Klippel-Feil syndrome resulted in almost full recovery although he was quadriplegic initially. This constellation of findings rarely has been reported in adolescence.

Deformities of the skull surfaces in infancy and childhood

Summary The most common alterations in the surface of the skull in infants and children have been described. The various methods of diagnosis and management have been reviewed with emphasis on the manner of distinguishing those that have clinical significance from the larger numbers that are essentially innocuous. Lesions of the scalp must be differentiated from tumors or other mass lesions originating in the calvarium. Exacting roentgenographic study is mandatory.